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NERVOUS DISEASES: 



THEIR 



DESCRIPTION AND TREATMENT. 



BY 



ALLAN McLANB HAMILTON, M.D., 

FELLOW OF THE NEW YORK ACADEMY OF MEDICINE J 

ONE OF THE ATTENDING PHYSICIANS AT THE EPILEPTIC AND PARALYTIC HOSPITAL 

BLACKWELL'S ISLAND, NEW YORK CITY; 

AND AT THE OUT-PATIENT DEPARTMENT OF THE NEW YORK HOSPITAL ; 

MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, 

ETC. ETC. ETC. 



WITH FIFTY-THREE ILLUSTRATIONS. 



V 



a 





PHI LA DE LP HI A: 

H E K" E Y C. LEA 

1878. 






I'll 



Entered according to Act of Congress, in the year 1878, 
HENRY C. LEA, 
in the Office of the Librarian of Congress. All rights reserved. 



I'll I I.ADKM'III A : 

i. i. i n s , i> it i n t i: B 
70.') Jiiync Street, 



TO MY FRIENDS 



FORDYCE BARKER, M.D., 



AND 



JOHN T. METCALFE, M.D 



PREFACE 



It has been my object to produce a concise, practical book ; and 
should the satisfaction be ever accorded me of knowing that I have 
made the subjects of Diagnosis and Treatment of Nervous Diseases 
more simple to my readers than I think they now are, I will be 
amply rewarded for the task I have undertaken. 

I have not considered Insanity, because I believe that this subject 
deserves much more extended notice than it could possibly receive in 
a book of this size and kind. 

I have deemed it advisable to include a short article upon Cerebro- 
spinal Meningitis, though, by many authorities, it is not regarded, 
strictly speaking, as a nervous disease. I think, if for no other 
reason, its interesting diagnostic relations entitle it to consideration. 

In conclusion, I wish to thank Drs. Loring, Janeway, Mason, 
Shakespeare, my resident physicians, Drs. Meyer, Naylor, Ryan, and 
Baldwin, and Mr. F. 0. C. Darley, for valuable assistance in the 
preparation of this volume. 

ALLAN McLANE HAMILTON. 

2 East 33d St., New York, 
May 1st. 1878. 



1 



CONTENTS 



INTRODUCTION. 

PAGE 

I. Hints in regard to Methods of Examination and Study — Ex- 
amination of the patient, symptomatology, etc. — Autopsical and microsco- 
pical examinations .......... 17-21 

II. Instruments used for the Diagnosis and Treatment of Ner- 
vous Diseases — The Thermometer, .Esthesiometer, Baraesthesiometer, 
Dynamometer, Ophthalmoscope — Apparatus for the Treatment of 
Nervous Disease — Electrical, rubber muscles, cauteries, etc. . . 22-34 



CHAPTER I. 

DISEASES OF THE CEREBRAL MENINGES. 

Cerebral Pachymeningitis — Acute, chronic — Chronic pachymeningitis with 
hematoma — Acute Cerebral Meningitis — Rheumatic Meningitis — Menin- 
gitis of the Aged — Acute Granular (Tubercular) Meningitis — Acute 
granular meningitis of the convexity — Chronic Cerebral Meningitis . 35-68 

CHAPTER II. 

DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Cerebral Hypercemia — Cerebral Hemorrhage — Cerebellar Hemorrhage G9-112 
CHAPTER III. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED). 

Cerebral Ancemia (acute, chronic, infantile) — Stomachic Vertigo — Auditory 
Vertigo 113-128 

CHAPTER IV. 

diseases of the cerebrum and cerebellum (contin1 bsd). 

Occlusion of Intra-cranial Vessels — Thrombosis — Embolism 

Thrombosis of the Cerebral Arteries — Thrombosis of Sinuses ami Veins 

Embolism of the Cerebral Vessels . ...... rj!>-ii7 



Vlil CONTENTS. 

CHAPTER V. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED). 

PAGE 

Cerebral Softening — Acute, chronic — Asemasia (aphasia) — Cerebral Scle- 
rosis — Diffused Cerebral Sclerosis ....... 148-184 

CHAPTER VI. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (CONCLUDED). 

Brain Tumors 184-203 

CHAPTER VII. 

DISEASES OF THE SPINAL MENINGES. 

Spinal Meningitis (acute pachymeningitis) — Acute and Chronic Spinal Me- 
ningitis — Spinal pachymeningitis — Spinal Tumors — Spinal Hemorrhage 
(Meningeal, Central) 204-222 

CHAPTER VIII. 

DISEASES OF THE SPINAL CORD. 

Spinal Hyper&mia (Spinal Congestion, Subacute Spinal Hyperemia) — 
Spinal irritation 223-232 

CHAPTER IX. 

DISEASES OF THE SPINAL CORD (CONTINUED). 

Inflammation of the Spinal Cord — Myelitis — Acute, chronic — Antero-Spinal 
Paralysis of Infancy— Of Adults 233-254* 

CHAPTER X. 

DISEASES OF THE SPINAL CORD (CONTINUED). 

Progressive Muscular Atrophy — Partial Facial Atrophy — Pseudo- Hyper- 
trophic Muscular Paralysis ........ 255-275 

CHAPTER XI. 

DISEASES OF THE SPINAL CORD (CONCLUDED). 

Posterior Spinal Sclerosis (Locomotor Ataxia) — Antero-Lateral Amyotro- 
phic Sclerosis — Lateral Sclerosis of the Spinal Cord — Tetanus . 276-807 

CHAPTER XI (. 

BULBAB DISEASES. <• 

Epilepsy — (The grave attack, tht light attack, irregular attacks) — Bulbar 
Paralysis 308-342 



CONTENTS. IX 

CHAPTER XIII. 

CEREBRO-SPINAL DISEASES. 

PAGE 

Cerebro- Spinal Meningitis — Cerebro- Spinal Sclerosis — Alcoholism — Acute 
— Chronic — Hydrophobia — Hysteria — Hystero-Epilepsy — Catalepsy 343-39 

CHAPTER XIV. 

CEREBRO-SPINAL DISEASES (CONCLUDED). 
Chorea — Paralysis Agitans — Exophthalmic Goitre .... 393-412 

CHAPTER XV. 

DISEASES OF THE PERIPHERAL NERVES. 

Neuralgia, facial, cervico-occipital, cervico-brachial, intercostal, or pleuro- 
dynia — Sciatic — Crural, visceral, ovarian, urethral, renal, etc. . 419-443 

CHAPTER XVI. 

DISEASES OF THE PERIPHERAL NERVES (CONTINUED). 

Neuritis — Ancesthesia — Tumors of Nerves ..... 444-452 

CHAPTER XVII. 

DISEASES OF THE PERIPHERAL NERVES (CONTINUED). 

Local Paralysis — Facial paralysis — Traumatic paralysis — Diphtheritic 
paralysis 453-469 

CHAPTER XVIII. 

DISEASES OF THE PERIPHERAL NERVES (CONCLUDED). 

Lead Poisoning — Functional Spasm — Tetany — Functional spasm with 
voluntary movements — Reflex spasm — Facial spasm without pain — Torti- 
collis — Professional Cramp — Writer's Cramp — Daucer's Cramp — Tele- 
grapher's Cramp, etc. etc 470-489 

Formulae ........... 490-505 



LIST OF ILLUSTRATIONS. 



1. Dr. Seguin's surface thermometer 

2. Sieveking's sesthesiometer 

3. Diagram for making records . 

4. Beard and Rockwell's piesmeter 

5. Mathieu's dynamometer 

6. The author's dynamometer 

7. Loring's ophthalmoscope 

8. The author's gas cautery 

9. Osteoma of dura mater 

10. Tuberculous matter about a vessel 

1 1 . Distended perivascular spaces with atrophy 

12. The topography of lesions 

13. Miliary aneurisms 

14. Multiple lesions with tongue atrophy . 

15. Instrument for applying heat and cold 

16. Tissue changes in softening 

17. Handwriting of an agraphic patient 

18. Handwriting of agraphia and cerebro-spinal sclerosis 

19. Location of island of Reil 

20. External indication of island of Reil . 

21. Choked disk . 

22. Tubercular deposit 

23. Sarcoma .... 

24. Gumma .... 

25. Psammoma .... 

26. Encephaloid .... 

27. Glioma .... 

28. Cerebellar aneurism 

29. Deformity of hand in cervical pachymeningit 

30. The consequences of spinal section 

31. Changes in muscular tissue in antcro-spinal 



(Duchenne) . 

32. Changes in muscular tissue in antcro-spinal 

(Duchenne) 

33. Changes in muscular tissue in antcro-spinal 

(Duchenne) 



. (Lancereaux) 

(Cornil and Ranvier) 

(Fothergill) 



. (Bourneville) 

(Bateman) 
. (after Turner) 
(after Leibreich) 



(Bristowe) 

(Charcot) 



paralysis of infancy 
paralysis of infancy 
paralysis of infancy 



PAGE 

22 
23 
52 
26 

26 
27 
28 
33 
39 
60 
78 
97 
98 
102 
111 
158 
166 
166 
16,x 
K:i 
188 
191 
191 
191 
1!»1 
192 

192 
197 
206 

•J 1 t 

245 
245 



2 1 5 



Xll 



LIST OF ILLUSTRATIONS. 



(Seguin) 

(Roberts) 



FIG. 

34. Changes in muscular tissue in antero-spinal paralysis of infancy 

(Duchenne) 

35. Antero-spinal paralysis of adults 

36. "Main en griffe" 

37. Atrophy of left shoulder 

38. Partial facial atrophy . 

39. The spinal curve in pseudo-hypertrophic paralysis 

40. Appearance of muscular tissue in pseudo-hypertrophic paralysis 

(Charcot) ........ 

41. Appearance of trophic bone-changes in locomotor ataxia (Charcot) 

42. The course of posterior nerve-roots . . . (Clarke) 

43. Pathological changes in locomotor ataxia and antero-lateral sclerosis 

(after Charcot) 

44. Lateral sclerosed patches 

45. Region of endemic tetanus on Long Island 

46. The pathology of hysteria 

47. Hystero- epilepsy .... 

48. Dr. Yeo's case of exophthalmic goitre 

49. Chart for the application of electricity 

50. Trophic change of the skin 

51. Sarcomatous neuroma . . . . 

52. Wire hook for the treatment of facial paralysis 

53. Reflex spasm from genital irritation . 



(Charcot) 



. (Yeo) 
(after Henle) 

(Foucault) 



PAGE 

245 
248 
256 
258 
267 
272 

274 

283 

285 

292 
294 
301 
382 
386 
413 
440 
445 
452 
458 
481 



NERVOUS DISEASES, 



INTRODUCTION. 

HINTS IN REGARD TO METHODS OF EXAMINATION 
AND STUDY. 

In beginning our consideration of the diseases which are to form the 
subject of the succeeding pages, it is well to start with systematic rul< - 
for investigation, and it is of paramount importance that we should pursue 
some plan which will enable us to avoid confusion, and assist us in making 
an accurate diagnosis by exclusion. One of the greatest misfortunes that 
can happen to the student is the possession of a large accumulation of 
badly-arranged facts, which are stored aAvay in the brain, like odds and 
ends in a garret. I, therefore, propose a scheme to be used in the exami- 
nation of patients, and would add a word of caution in regard to the error 
many of us make in too readily accepting and isolating nervous symptoms 
as distinct, which, after all, may be expressions of some general disorder. 

We are to determine the existence and relation of disorders of motility 
and sensation, as well as mental symptoms, defects of speech, sight, or 
hearing, together with the causes which enter into their production. 

Examination of the Patient Sex, age, temperament, appearance, 

duration of present disease, existence of complicating maladies, previous 
history, hereditary predisposition, habits. 

Symptomatology — Motility, location of loss or increase (one side or 
one-half of body?), groups of muscles or single muscles, face, trunk, or 
extremities, lateral or bilateral, symmetrical or unsymmetrical, loss or 
exaggeration of electro-muscular contractility, fibrillary contractions, mus- 
cular power, deformities or contractures; atrophy or hypertrophy, general 
or partial ; spasms, tonic or clonic, attended or unattended by loss of con- 
sciousness ; pain; degree of violence. 

Tremok — Local or general, increased or controlled by will. " fine" 01 

" coarse;" time of day, continuous or at intervals; Subsidence or continu- 
ance during Bleep. 

Incoordination of upper or lower extremities, variety of action in 
which it occurs; gait ; aggravation by closure of eyes; loss of muscular 

ense ; loss of locating power. 
2 



18 INTRODUCTION. 

Vertigo Variety ; concomitant phenomena. 

Sensation. — General or partial anaesthesia; dysesthesia or hyperes- 
thesia; condition of reflex excitability; susceptibility to painful impres- 
sions: temperature; tactile sensibility; sensibility to pressure; pain, 
localized or general ; character of pain, neuralgic, terebrating, dull, or 
paroxysmal; time when aggravated; its associations; time of transmission. 

Disorders of Organs of Special Sense. 

Eyes Nystagmus, strabismus, conjugate deviation (see article Cere- 
bral Hemorrhage), retinal changes, pupillary changes, ptosis, diplopia, 
amaurosis. 

Ear Deafness, subjective noises, discharge. 

Speech Aphasia, slow speech, clumsy speech, ataxia, loss of speech 

(mutism). 

Psychical Disorder — Illusion, hallucination, delirium, mania, me- 
lancholia, delusions, loss of memory, loss of consciousness, imbecility, idiocy, 
excitability, dementia. 

.Miscellaneous — Character of cutaneous surface, changes in tempera- 
ture, variation in salivary secretions, changes in pigmentation and appear- 
ance of hair, perspiration, etc. 

Exciting Cause ; Diagnosis; Treatment. 

This list, though imperfect, will, I think, enable the observer to pursue 
a systematic course in examining his patient. He should, at the same 
time, take careful notes for future reference, so that variations in the 
symptoms and changes of treatment may be remembered. 

Before leaving the subject of examination, I wish to refer to the value 
of post-mortem examination and microscopical investigation of the morbid 
anatomical changes. These subjects belong more properly to special works 
upon pathology and microscopy, but it may not be amiss to add a few hints 
to those already given in regard to certain important steps to be taken. In 
r<nio\ ing the calvarium the thickness of the cranial bones should be noted, 
as well as the condition of the diploe; but extreme care should be employed, 
in sawing through the bone, not to wound the meninges and brain-sub- 
Btance beneath; for the saw-teeth may unexpectedly tear through, lace- 
rating and injuring these parts, so that they may be almost useless for sub- 
sequent examination. After the skullcap has been removed, the observer 

Bhould be on the lookout for I'acchouian bodies, and ready to recognize any 

adventitia that maj be attached to the dura marer. The condition of the 
longitudinal Binus and veins which arc contained! in the dura mater should 
be examined as to their fulness, etc. \ the thickness, \ ascularity, color, and 

opacity of llnir tissue should also be carefully noted and then an incision 



POST-MORTEM EXAMINATION. 19 

may be made, and this membrane slit up with a pair of blunt-pointed 

scissors, or it may be cut around at the level of* the saw cut. The arach- 
noid and pia mater are then to be inspected: the existence of effusion, 
either serous, purulent, or bloody; and the presence of granular deposit or 
vascular changes noted. The brain should be lifted back, and the cranial 
nerves carefully cut as near as possible to their points of exil from the 
skull, the optic first, and then the carotid arteries and posterior ner 
next the tentorium, and finally the other nerves, vertebral arteries, and 
the spinal cord as low down as possible, taking care not to make pressure 
by insinuating the finger into the foramen magnum. The brain may then 
be removed. 1 If it is desired to remove the cord, the skin and muscular 
tissue of the back should be divided and thrown back, and the spinous 
processes and laminae exposed. These latter should be sawn through on 
each side and carefully raised by the blade of the chisel. When the brain 
is removed, it should be placed with the base downwards, and the appear- 
ance of the convolutions noted, the membranes having been removed. 
Evidences of pressure are to be looked for, and color is to be noticed, as 
well as the depth of the sulci and superficial evidences of softening or scle- 
rosis, morbid growth, and infiltration. The organ may be turned over, 
and the arteries at the base inspected in regard to the existence of anom- 
alies, aneurisms, degeneration, thrombosis, or embolism. The fissure of 
Sylvius may be gently examined, and the middle cerebral traced up for 
some distance. The cranial nerve-trunks are to be carefully noticed, and 
if any suspicious appearance is observed, a section may be removed for 
microscopical examination. The crura and pons are to be examined care- 
fully for softening extravasations and the like, and the appearance of the 
basal parts of the hemispheres next noticed. The brain-substance may 
be inspected after cutting through the corpus callosum, and turning each 
hemisphere gently back, or by slicing off the brain-substance witli a broad 
sharp knife previously dipped in water or alcohol, so that the white matter 
may be examined at different levels. The condition of the ventricles should 
be noticed as to the effusion of serum or blood. The parts at the floor of tin- 
lateral ventricles deserve special study, and the corpora striata should be 
inspected very attentively, the extra-ventricular and intra-ventricular parts 
being carefully sliced. The fulness of the vessels in the deep parts of the 
brain, the existence of patches of softening or induration, and the pressure 
of cysts, tumors, or morbid growths should be looked for. It is always 
advisable in cases where aphasia has been a symptom during life, to care- 
fully inspect the anterior convolutions, particularly the third frontal, 
which is the generally acknowledged seat of the lesion, and we may do this 
by entering the fissure of Sylvius* 

It is hardly necessary to allude to the importance of carefully examining 
the medulla and the roots of the various cranial nerves, and for this pur- 

1 Removal, <n masse, of the brain and its membranous coverings should never 
be attempted; the result of such a procedure being mechanical injury, which 

reduces the organ to a pultaeeous mass, rendering it unlit tor examination. 



20 INTRODUCTION. 

pose it is advisable to remove such parts as are wanted for subsequent 
microscopical examination. The cord must be examined critically in cases 
of spinal disease, and the same directions are given for its inspection. Sus- 
pected portions may be cut out and laid aside, care being taken to secure 
as much of the external roots as possible. In special cases nerve trunks 
or peripheral nerves may be exsected for future examination, and in cases 
attended by muscular atrophy and degeneration it is well to ascertain the 
morbid changes in the muscles. If we desire to use the microscope it is 
generally necessary to harden the tissues, although fresh nervous substance 
may be teased apart in glycerine or serum by needles prepared for the pur- 
pose It we prefer the first method we may put such masses of the brain 
or cord as we desire to harden into Muller's fluid, which is prepared as fol- 
lows : — 

R. Potass, bichromat. 50 grammes, 

Sodic sulphate, 20 grammes, 

Water, 50 cubic centimetres : 

Or, what is better, the solution recommended by Prof. J. W. S. Arnold, of 
the Medical Department of the University of the City of New York: 

R. Ammon. bichromate, 11 grammes, 
Methyl alcohol, 320 grammes, 
Water, 640 grammes. 

Care should be taken not to secure too large specimens, as they do not 
harden thoroughly, the exterior becoming hard while the interior is dif- 
fluent and useless. They should be left in this solution for a month or six 
weeks, but not till they become granular or cheesy, for then it is impossible 
to make a good section, as the tissue is apt to crumble under the razor. 
At the end of this time, or when the tissue is quite firm, it may be removed 
and placed in a fifty per cent, solution of alcohol and water. The speci- 
men may be examined to test its hardness by making sections with a razor 
from time to time. If a very thin section can be made with a moistened 
razor without parting, adhesion, or crumbling, it may be considered to be 
in lit condition for removal from the hardening solution. A solution of 
bichromate of ammonium, 15 grains to the ounce of water, is an excellent 
hardening solution, in which the specimen may remain until it has been 
uniformly Baturated, and hardening has commenced, and then it is to be 
removed and placed in a solution of chromic acid, two grains to the ounce 
of water, where it is to remain until hard enough for culling. This is the 
process recommended by Dieters. The specimens may be taken out and 
kepi lor use ill dilute alcohol till they are needed. 

When the hardened tissue is to be examined, it is to be imbedded in 
pith or paraffine, and either placed in a section cutter, or held in the hand. 

By practice, this latter procedure becomes quite] easy, and \^\-y thin sections 
may be made. A piece of brain or a length o£«ord of a convenienl size is 
surrounded by elder pith previously prepared to receive it, and bound in 

place by ;i string or piece of line copper wire. When moistened, the pith 

swells bo thaf the tissue receives uniform pressure and support. If the 



MICROSCOPIC EXAMINATION. 21 

paraffine process is to be employed, the tissue is to be carefully dried and 
placed in a small paper mould which is afterwards filled with melted paraf- 
fine, which should not be too hot, 1 and care should be taken to exclude air- 
bubbles — when cool and solid the upper part of the paper may be torn 
away, and the specimen is ready for cutting. A flat razor is the best 
instrument of which I know for ordinary work. Its blade should be dipped 
in a saucer containing alcohol placed conveniently by, and the face of the 
section should be moistened from time to time. The individual holding 
the mould firmly between the thumb, forefinger, and second finger of the 
left hand, cuts away a portion of mould and tissue so that a level surface is 
left exposed ; then, with moistened razor, he plants the blade, and slowly 
cuts a thin slice of paraffine and tissue together; this is removed by a 
camel's hair brush which has been dipped in alcohol, and next dropped 
into a small vessel containing dilute alcohol, and then placed in the stain- 
ing fluid, which may be the following : — 

&. Carmine (pure), gr. xx, 

Liq. ammonia.', q. s. ut dissolve, 

Glycerin*, 

Aquae, aa §ij. — M. 

After being allowed to soak for several hours or days, the sections are 
removed and dropped into water slightly acidulated with acetic acid. They 
are now to be placed in absolute alcohol for a short time, and afterwards 
placed in oil of cloves until they become transparent. A perfectly clean 
slide is procured, upon which one of them is placed and a drop (not too 
large) of Canada balsam is next applied. It is then covered by a thin 
glass cover, care being taken to exclude air-bubbles. Various preparations 
are used to stain nervous tissues; for instance, a solution of chloride of gold 
will stain the nerve fibres, and render them more distinct ; hematoxylin 
and osmic acid are also used, and the black anilin process of Herbert Major 2 
produces the most beautiful results. These manipulations, however, are out 
of place here, and I would refer the reader to any one of the excellent text- 
books that have appeared during the past few years for more explicit direc- 
tions. 

It is often necessary to make sections in all possible directions and posi- 
tion-;, and to do this properly the microscopist must not only have practice 
but patience and care. It is advisable to procure at least two objectives, 
one for coarse appearances, and the other tor minute changes, and I would 
suggest that these should be an " inch" and a "quarter inch.*' 

1 1 have recently used metallic bottle caps, which may be easily procured. 
When the paraffine is cool the metal may be stripped off. 

2 West Riding Reports, vol. v. 



22 



INTRODUCTION. 



INSTRUMENTS USED FOR THE DIAGNOSIS OF NERVOUS 

DISEASE. 



It is essential that we should possess certain instruments which shall be 
more valuable and exact than our unaided senses, so that we may not only 
make reliable investigations, but compare from time to time 
Fig- 1. such variations as may occur in the patient's condition. 

Those I propose to describe are intended for examinations 
of temperature and sensory changes, and for the detection of 
altered motility. 

The Thp:ii:\iometer There are several instruments 

made for the purpose of determining variations in tempe- 
rature, and though some are of extreme delicacy, I do 
not think it will be worth while to recommend them, as 
they are bulky and troublesome, and are better adapted for 
experimental purposes than actual clinical use, and among 
these is Lombard's instrument. 

In Dr. Seguin's surface thermometer we possess an admi- 
rable little instrument for testing the surface temperature. It 
has an expanded base, and may be applied to the surface of 
the body, taking care to cover the top by a perforated piece 
of thin rubber or leather. A coat or two of shellac varnish 
to the upper part of the bulb will answer the same purpose, 
viz., that of preventing the mercury from being affected by 
the temperature of the room. For the determination of deep 
temperature we may avail ourselves of any of the good selt- 
registering instruments. Two surface thermometers should 

J be used, one on the sound, and the other on the affected side 

of the body, and the deep temperature may be taken at the 
;f same time for comparison. A new form of surface ther- 

mometer has recently been made; in England. The glass 
tube is spirally coiled upon itself and inclosed in a circular 
box. This form lias the merit of being unaffected by other 
than the body temperature. 

BecquerePs disks I have found to possess extreme delicacy, and if pro- 
perly constructed the variation of a fraction of a degree may be readily 
appreciated. They consist of delicate strips of two sensitive electro-nega- 
tive and positive nictals, imbedded in a. handle. Copper and bismuth are 
generally iised. By proper connections they are put in communication 

with a delicate galvanometer which registers the feeble thermo-electric 

current \\ hich La generated. * 



Dr. Segul > 

Mir ace 

Thermometer 



The ^ESTHESIOMETKB was first suggested bv Sie\eking, and has since 

been modified by different individuals. We have several different varie- 
ties to choose from, bul m> one is better than the original instrument of 



THE iESTHESIOMETKR. 



23 



Sieveking, which is also used and recommended by Brown-Sequard. It 
is made of brass or steel, and very closely resembles a shoemaker's mea- 

Fig. 2. 





— a 




1 

1 

1 
1 

1 




— o 


2 




i 




— DO 


.- 




i 




- CM 

- o 


14 








!* 














<9 




i , i 






r^^^^" 



Sievcking's iEsthesiometer. 



sure. The movable slide and permanent arms at the end arc sharp 
pointed. The bar upon which the free slide moves is ruled in centi- 
metre-. 

The other aesthesiometers are mostly shaped like dividers, and whether 
tliev be Hammond's or Carrol's, they are open to the objection thai the 
points are liable to be unconsciously approximated when the instrument 
is removed, so that the result of investigation is somewhat unreliable. 

Carrol's aesthesiometer has one advantage. The points are bifurcated, one 
arm ending in a bulb, while the other is sharp, so that analgesia as well as 
anaesthesia may be tested. 



24 INTRODUCTION. 

Dr. E. C. Seguio has made a very decided improvement upon the original 
instrument of Sieveking. lie has had it constructed of aluminum, and of 
a smaller size, so that it is light, and may be easily carried in the pocket- 
case. 

The principle upon which the assthesiometer is constructed is the fol- 
lowing : The normal receptivity of tactile impressions enables the subject 
to distinguish two points which are brought simultaneously in contact 
with the skin. This susceptibility varies greatly in different regions in 
proportion to the delicacy of tactile sensation located therein. If there 
be loss of sensation as an accompaniment or result of nervous disease, of 
course the distance between them will have to be increased before the 
points will be felt as two. In hyperesthesia they may be much more 
nearly approximated and distinguished as two than in the anaesthetic 
state. 

The average distance at which the two points of the instrument can be 
felt in the normal state are as follows : — 

Point of tongue ........ £ line. 

Red surface of lips ........ 2 lines. 

Palmar surface of third finger . .... 1 line. 

Tip of nose 3 lines. 

Metacarpal bone of thumb . . . . . 4 " 

Skin of cheek 5 " 

Mucous membrane of hard palate . . . . G " 

Dorsal surface of first finger . . . . . 7 " 

Dorsum of hand over heads of metacarpal bones . . 8 " 

Mucous membrane of gums . . . . . 9 " 

Lower part of forehead . . . . . . . 10 " 

Lower part of occiput . . . . . . . 12 " 

Back of hand 14 " 

Neck under lower jaw . . . . • . - . 15 *' 

Vertex 15 " 

Skin over the patella 16 " 

Skin over the sacrum . . . . . . 18 " 

Skin over the sternum . . . . . . . 20 " 

Skin over cervical vertebras . . . . . . 24 " 

Skin over middle of hack ...... 80 "' 

Skin over middle of the arm 80 '• 

Skin over middle of the leg ...... 80 l< 

Certain precautions must be taken when using the sesthesiometer, oi 
else our examination will be unsatisfactory in ihe extreme; we must not 
depend in all eases upon the patient's statement, but exercise tact in getting 

from him satisfactory answers, and not guesses. There seems to be in some 

individuals a discouraging stupidity which prompts them, in answer to the 
question, •• I Cow many points do you feel ? " to oftentimes reply " Three," 

when they know that the instrument has but, two points. It is of the 

greatest importance that the patient's eyes should be covered, or that he 
should close them, as he will unconsciously look at the instrument during 
it~ application. It is also of momenl that the points should be fairly and 



iESTHESIOMETER DYNAMOMETER. 25 

at the same time applied to the skin, one not being pressed more than the 
Other, and finally, it may be stated that they should not be applied at any 
place where the clothing has rubbed or chafed the surface. 

Fin. 3. 




Diagram for making records.— Romas, numerals show anaesthetic indicati 
mal sensibility. 



the others nor- 



The Bar^esthesiometer of Eulenburg, modified by Beard & Rock- 
well, has been used as a means for the determination of the individual 
sense of application of weight which is lost in various forms of paralysis 
and anaesthesia. It consists of a sp ing which is impinged upon a piston, 
both being placed in a tube or cylinder, and the rod connected with the 
piston having a broad expansion at its outer end. This disk is placed 
upon the body, and the spring impinged, registers on a scale the amount 
of pressure made before it is recognized by the individual. 



The Dynamometer. — Various forms have been devised, that in general 

U86 being the invention of Mathieu. It COnsist8 of an elliptical Spring 

which when compressed in the hand registers upon an index the force I \- 
erted. When the needle is forced ahead it remains at the point it bad 

reached when pressure was remitted, and the spring expands. Its disad- 
vantage lies in the inequality of pressure made at different times, the 

bulky character of the apparatus, and its inadaptability to other uses. 



26 



Fie 4. 



INTRODUCTION. 

Fig. 5. 




I 



tl 




Mathieu's Dynamometer. 





Board & Rockwell's 
Piesmeter. 



Having recognized the necessity for an instrument 
that Mould meet the therapeutical requirements not 
possessed by those of Mathieu or Duchenne, I have de- 
vised that figured in the appended illustration. It con- 
sists of a long glass tube (2) which dips into a small 
bottle filled with mercury. In connection with a bent 
brass pipe (3) is a rubber tube which terminates in a 
closed rubber bulb (5). When this bulb is compressed 
the mercury is forced up in the glass tube, the end of 
which is closed (1). Attached to the tube is a scale 
marked on one side in pounds, and on the other by 
marks separated by regular intervals for the purpose of 
making comparative estimates. As fifteen pounds' pres- 
sure to the square inch is required to compress a given 
body of air into one-half its original space, of course a 
force of fifteen pounds' pressure brought to bear upon 
the bulb would be required to press the column of mer- 
cury half way up the scale. The advantages of this apparatus are the 
following: — ♦ 

1. Its simplicity. 

2. The adaptability of the rubber bulb to receive pressure exerted by 
all flexors of the hand. Mathieu's spring is only acted upon by a limited 
number; at the same time, therefore, the test is not a true one. 

.'5. The action of the muscles is the same at different times. The same 
group of muscles always being brought in play, accurate comparative tests 
may be made from day to day. 

1. The pari receiving the pressure is of a convenient shape to he used 

hv persons with either small or Large hands. 

.">. It is accurate ami always gives reliable indication of the pressure 
brought to hear. 

An instrument styled the dynamograph, which is a combination of the 
dynamometer ami the writing part of the sphymograph, is advocated as a 

valuable aid in diagnosis. The variation of iiuperfectlv sustained pressure 

i- recorded upon a Blowly-moving card. I consider the apparatus a. use- 
less invention, a- the results obtained must he of the clumsiest hind. In 
fact no instrument but the myograph, of which there are several forms, 
is of any use lor delicate observation. 



THE DYNAMOMETER. 



27 



I have combined the rubber bulb with the drum of* Marty, and am 

enabled to obtain gross variations with tolerable accuracy. The drum lias 
two pipes, one of which is connected with the rubber bulb, while another 

is attached to the lower end of an open glass tube. The bulb-drum cavity 



Fie. 6. 




The Author's Dynamometer. 



and a part of the tube are filled with colored fluid, so that the fluid in the 
latter reaches a mark at about the middle of it< Length. The patient grasps 
the bulb and makes enough pressure to force the fluid in this tube ton mark 
-lightly above the other. The sustained voluntary effort required to keep 
the fluid at this point necessitates some delicacy of muscular coordination, 
and should this be impaired there will be expansion of the drum -head and 

consequently irregular tracings upon the cylinder of the registering appa- 
ratus. This cylinder should be covered by a piece of smoked paper, and 
the stylet placed in apposition thereto. 

In alcoholic tremor, commencing sclerosis, and the metallic tremor-, we 

may obtain very beautiful tracings. 



28 



INTRODUCTION. 



The Ophthalmoscope — The parts composing the ordinary ophthal- 
moscope are the following: A concave mirror perforated at its centre, a 
series of lenses by which the refraction in the subject's or observer's eye 
may be corrected, and a bi-convex lens. The three forms in common use 
are those of Liebreich, Loring, and Knapp. The two latter are essentially 
alike in construction, and the first is quite primitive, usually of bad con- 
struction and quite unreliable. 

Fig. 7. 




Loring 's Ophthalmoscope. 



In the examination with this instrument great care should be taken by 
the observer to determine whether he or his subject possesses errors of 
refraction, and if so to correct them with the proper lenses. In the modern 

Ophthalmoscope a number of lenses are held in a revolving disk behind 

the mirror. 

For more specific directions the reader is referred to Dr. Loring's ad- 
mirable little work. 1 

To examine the eyes of a patienl properly, the observer may follow the 
concise directions laid down by Hutchinson. 3 

1 Determination of Errors of Refraction with the Ophthalmoscope. E.G. 
Loring. Wm. Wood & Co., N. V. 

Jonathan Hutchinson. Clinical Reports of London Hospital 1867 8, p. 182. 



THE OPHTHALMOSCOPE. 29 

" Having placed the patient's head in such a manner thai the light (a 
lamp, candle, or gas-light) is on a level with his temple, and slightly be- 
hind it, and his face, as a consequence, in shadow, the observer Bits in 

front and applies the ophthalmoscope mirror to his own eve. lie should 
keep both eyes open that lie may see where the light falls, and then move 
the mirror until the light falls full on the pupil of his patient. In a mo- 
ment he will perceive the first fact which this instrument reveals, that the 
fundus is not black, as it has always appeared to he before, but that it i- 
of a brilliant fire-red. He will, however, see nothing of the fundus dis- 
tinctly, only a general red reflex. Now at this point the student must 
stop awhile and use his mirror, to inspect, first, the transparency of the 
cornea, and, next, that of the lens and vitreous, and to do this he must 
make the patient move his eye in various directions. After a little prac- 
tice he will be able to manage his light well, and to throw it with preci- 
sion wherever he may wish, and to keep it steadily on any given part. At 
a first lesson he may even, with advantage, practise for a while by illumi- 
nating the second button of the patient's waistcoat. Tact in directing the 
light having been obtained, we may now proceed further. Instruct the 
patient to look, not full in your face, but over one shoulder; if you are 
inspecting his right eye, over your left shoulder. You will, when he does 
this, notice at once that the tint of the light reflected from his fundus is 
changed, that it is no longer fire-red, but canary-yellow. The reason of 
this is that a different part of the fundus is exposed to view, that, namely, 
of the optic disk itself, which is much lighter in color than the rest. The 
area of yellow is xevy large — occupies, indeed, the whole of the field. 
while we know that the disk itself is very small. This proves that the 
objects thus indistinctly seen are immensely magnified. Magnified by 
what? By the patient's own eye, which, as we have said, is equivalent 
to a lens of one inch focus. 

" Hitherto we have seen nothing distinctly, but if the observer now 
brings his head very close to his patient's face, he will be able with more 
or less facility to observe the details at the bottom of the eve, the trunks 
of vessels of the retina, the optic disk, etc. etc. All these will he seen 
very large indeed, being still magnified by the patient's eye. What he 
sees now is equivalent to type looked at through a. one-inch lens, placed 
exactly one inch in front of it." 

Without entering into an extended discussion as to the value of this 
instrument a8 a means of diagnosis, it will be well to state frankly that I 
do not believe that it possesses any positive value in the diagnosis of brain 
disease, except where the condition of the fundus is the result of an or- 
ganic disease of the />r<tin or cord, or when it i< pi>-«-il>le to connect BUCh 
disorders with errors in refraction. 

In making this statement 1 shall, perhaps, find many opponents, hut I 

nevertheless have many powerful allies. A distinguished author recently 

took it into his head to call those who differed with him. in regard to the 
diagnostic value of the ophthalmoscope in functional circulatory disturb- 
ances, "pert pretenders." How far this accusation is true the reader 



30 INTRODUCTION. 

may determine after consulting the really convincing articles of Lofing, 1 
Arbuekle, 2 Albntt, and others, which prove beyond question that the 
fundus of the eye is rarely any index of the cerebral circulation. 3 

Bouchut, 4 Panas, 6 Albutt, 6 Hammond, 7 Bell, and others, have written 
extensively, and have furnished a large number of clinical reports of oph- 
thalmoscopic changes coexistent with cerebral tumors, meningitis, soften- 
ing, effusion, cerebral hemorrhage, general paralysis, locomotor ataxia 
and other forms of sclerosis, epilepsy, and the syphilitic and ursemic neu- 
roses. Hutchinson, 8 of Philadelphia, in an admirable article, gives many 
of these cases, and shows the real value of the ophthalmoscope, especially 
when an examination of the fundus reveals choked disk and optic neuritis, 
but I will speak more fully in regard to this subject when we come to the 
discussion of special diseases. 



APPARATUS FOR THE TREATMENT OF NERVOUS 
DISEASE. 

Elei TRICAL. — Two forms of apparatus are required — one for the gal- 
vanic^ the other for the induced or Faradlc currents — as well as the 
necessary electrodes. 

As we know, the galvanic current is derived directly from a battery or 
pile, the first ordinarily consisting of two elements, which are contained 
in a vessel filled with some exciting solution, and the latter of plates of 
metal placed one above the other, and separated by disks of felt or paper 
moistened with a solution of salt or acid. This last apparatus is rarely 
used. 

One vessel or cell of the form I first described constitutes a simple bat- 
, , » 

1 Am. Psychological Journal, Nov. 1876. 

2 West Hiding Reports, vol. v. p. 148. 

8 Dr. Loring says, in concluding an admirable paper: "By the experiments 
considered in the foregoing remarks two alternatives are forcibly presented to our 
mind: either that the circulation of the eye is not a reflex of the circulation of 
the brain, though derived directly from it; and thus agents which affecl pro* 
foundry the one have little or no influence on the other; or, if the retinal circu- 
lation is a reflex of the cerebral, it follows that the influence exerted on the cir- 
culation of the brain by agents at our command, remedial or otherwise, is very 
much less than heretofore supposed. 

•• I cannot but think that the former alternative is the more rational, ami from 
thai \<i'\ independence of the two circulations there is reason to fear, so far as 
functional, and especially mental diseases, are concerned, that there never will be, 
;iu\ more than there now is, any art to read the mind's construction in the eye." 

4 l)u Diagnostic defl Maladies du System \er\eii\ par l'( )|tht haliuoseopc. 

Paris, 1876. * 

I,., France Medicale, Feb. 26, ik7<;. 
' Med. Timed and Gaz., vol. i., p. i!>.~>. and seq. 
7 Diseases of the Nervous System. New York. 1876. 

■ l'hil. .Med. Times, May 8, I s 7 .> . 



APPARATUS FOR TREATMENT. 31 

tery, and two or more, with the poles alternately connected, a compound 
battery. 

Two qualities of eleetric force are generated by a battery of this kind : 
1. Quantity; 2. Intensity. The latter is the characteristic which makes 
it valuable as a means for the production of muscular contraction and 
nerve stimulation. 

The Faradic current is derived from a galvanic cell primarily, and is 
developed by its passage through a coil of wire wound about a central core 
or bundle. Two currents are induced therein: one the primary induced, 
the other the secondary induced. The first is less coarse and violent in 
its effects than the other. 

For a more extended description of electro-physics, physiology, and 
therapeutics, I would refer the reader to any of the works mentioned at the 
foot of this page. 1 

For the production of the galvanic current, we may avail ourselves of 
either one of the permanent batteries ; the cells of which may be set up 
in the cellar, and the wires carried to a proper board in the office, con- 
taining apparatus for their selection; or we may use the ordinary portable 
galvanic battery, many styles of which are made. 

I have given the Leclanche battery a fair trial, and now do not recom- 
mend it, as it is dirty, inconstant, and rapidly loses power. The " maga- 
zine" battery of Chester, in which the peroxide of lead is substituted for 
the black oxide of manganese in the porous cell, is much better. The old 
Daniel's cell is, I am convinced, the best of all, and whether in the form 
of the Siemens and Halske, or Hill modification, is all that can be desired. 

The table board of Fleming and Talbot, of Philadelphia, or the arrange- 
ment known as the " cabinet battery," which is made by the Galvano- 
Faradic Company of New York, is admirable for office use. 

The Galvano-Faradic Company of New York construct a very good 
portable battery of thirty-two cells, and I would recommend it for general 
use, as it is admirably simple and effective. 

The Faradic instrument should be provided with an attachment for the 
slow or rapid interruption of the current, an addition to the ordinary bat- 
tery, which will be found of immense advantage in certain forms of 

1 Either of these works will be found practically useful to the student : — 
Tibbit's Handbook of Medical Electricity. 
Reynolds' Clinical Uses of Electricity. 
Althaus's Electricity, Theoretical and Practical. 
Poore : A Text Book of Electricity, etc. 
Lincoln's Electro-Therapeutics. 

Beard and Rockwell's Medical and Surgical Electricity. 
Hamilton's Clinical Electro- Therapeutics. 
Duchenne's de 1' Electrisation localise. 1872. 
Onimus et Legros, Traite" d' Electricity Med. 
Benedikt Elektrotherapie, 1874 5. 
Ziemssen, Die Electricital in der Med.. 1872. 
Besides, the works of Rosenthal, Erb, Meyer, Eulenburg, and others 



32 INTRODUCTION. 

paralysis. The instruments of the two firms I have mentioned, besides 
those of Drescher and Kidder, are all good. 

Two or three cotton-cloth covered electrodes of different sizes, or flat 
sponges with rubber backs, with fine wire pole cords instead of the flimsy 
gold-thread connections in present use, which oxidize and break, will be 
needed, as well as a bundle of fine wires held in a handle, which is 
known as the electric brush. 

Rubbeb Muscles, etc Dr. Van Bibber, of Baltimore, has devised 

a very useful apparatus for the treatment of paralysis, especially of lead 
paralysis. It consists of a strap for the hand or other part which needs 
support, and one for a point of attachment of the muscle. When properly 
applied, the rubber pipe, which takes the place of the paralyzed muscle, 
raises the hand, so that the strain upon the enfeebled muscle is relieved. 
Dr. Van Bibber has also used court plaster for the treatment of ptosis and 
other minor paralyses. 

Tite Hypodermic Syringe, Ether Spray Apparatus, and Spinal 
and Cranial Ice Bags, should be procured by every physician who has 
occasion to treat this class of diseases. 

Cauteries. — Until a few months ago the old form of cautery was used 
almost exclusively. These are of iron, and are sometimes platina covered. 
When they are needed, they are heated in the flame of a Bunsen burner, 
Russian blast lain]), or some such contrivance, but lose their heat very 
rapidly, and generally assume a dead red color when they are to be ap- 
plied. The glass rods, heated in a like manner, though somewhat more 
convenient, become very quickly cool. 

Dr. J. J. Putnam, of Boston, exhibited at n meeting of the American 
Neurological Association the first gas cautery which was seen in this 
country. In some respects it was imperfect. It produced a noise which 
was harrowing to the patient, and it was expensive and cumbersome. 
The apparatus consists of two pipes (one within the other), which convey 
air or oxygen and illuminating gas to a common burner. These tubes are 
connected with stopcocks (Fig. 8, vf, 2, 2), which enable the operator to 
Control the Bize of the flame. A handle ( 1 ) covered at one end by a 

shield, completes the body of the instrument. At the end of the burner 

i- :i dome of platinum, which is fastened to the end of the burner by a, 
ring and clamp (/>'. I), so that, by a simple movement, the dome can be 

removed and replaced by another. About the lower vd<j;c of the pla- 
tinum, is a small collar of wire gauze, expanded at its lower end, which 
prevents the escape of any return flame (/>). 

From the two stopcocks pass rubber tube*;, one to the gas-burner, the 
other to a T of brass pipe, the middle branch of which extends into a 

large spinal ice-hag (. •!,.'!). This 18 covered by a strong net. To the 

other branch ;i rubber ml e is attached. This tube terminates in an ordi- 
nary rubber atomizer-bulb. 



CAUTERIES. 



33 



At the T-piecc is a small hook (A, 4), by which the ice-bag or air 
reservoir can be attached to the button-hole of the operator. 

Fig. 8 




The Author's Gas Cautery. 



The advantages I claim for the modification of the instrument I have 
described are the following: — 

1. The adoption of a jet which prevents all hissing or noise, and still 
produces a very powerful blast. 

2. The apron of wire gauze, which prevents the return of flame, thus 
obviating the danger of burning parts that we do not wish to affect. 

3. The large bag, which acts as a reservoir, so thai the operator need 
not use the rubber bulb nor watch the burner after it is tilled. 

4. The hook, which enables him to suspend the bag and t idling from 
his person, thus removing all drag. 

The general advantages of tins form of cautery are important. A uni- 
form heal may be kept up for hours with very little exertion. The fur- 
nace, which is not only inconvenient, dirty, and alarming to timid people, 
but is a slow method, is done away with. In les> than a minute the 

platinum dome can be heated to whiteness. 
3 



34 INTRODUCTION. 

The cauteries of Pacquelin and Guerard, of Paris, are both good. In 
them the vapor of benzine (which should be very pure) is forced with air 
upon a piece of hot platinum. These are excellent substitutes for the 
cautery I have just described, in the country where there is no gas. 

Dr. Hammond has recommended that the spinal ether spray be used to 
deaden pain ; but not only is there danger of an explosion when this pro- 
cedure is tried, but it seems to me that the very object of the operation, 
revulsion, is not accomplished, as the peripheral filaments are of necessity 
benumbed. 



ACUTE PACHYMENINGITIS. 35 



CHAPTEE I. 

DISEASES OF THE CEREBRAL MENINGES. 

All of the investing membranes of the brain maybe the seat of inflam- 
matory action, but it is almost impossible in certain instances to make 
distinctions between inflammation of the arachnoid and pia mater, though 
this has been attempted by Parent-Duchatelet, Lallemand, and others. AVe 
will, therefore, have to content ourselves with a division founded upon the 
duration, intensity, and coexisting diseases of the general system, and 
limit our regional diagnoses to forms which may be called meningitis of 
the convexity and meningitis of the base. 

In respect to certain circumstances which modify the appearance of the 
disease we may divide these neuroses as follows : — 

Cerebral pachymeningitis, \ '. 

(Inflammation of the dura mater), 1 * 10mC ' 

C Chronic, with hematoma. 

r Basilar, 
Acute cerebral meningitis, J Of the convexity. 



Granular. 



Chronic cerebral meningitis. 



PACHYMENINGITIS (INFLAMMATION OF THE DURA). 

Two forms of pachymeningitis are to be met with, one of which is acute 
and is the direct result of injury or disease of the cranial hones, and is 
generally fatal in a short time; and the other, of a chronic nature, which 
may either remain after injury, or arise from seme intracranial cause, or 
perhaps be the result of general disease, or old age. 

ACUTE PACHYMENINGITIS. 

Symptoms After the traumatism, or when the external disease has 

invaded the intracranial cavity, the first symptom is usually severe and 
localized pain, which finally extends with the inflammation, and becomes 
diffused over the entire head. 

Rigors, alternating with elevation of temperature, which may sometimes 
attain 105° or L06 F., occasionally spasms of the arms or legs, are ordi- 
nary symptoms; and if the condition he a very acute one, there max he 
general convulsions, or perhaps a partial paralysis, which is unilateral. 

Delirium usually supervenes in from three days to a week, and coma 



36 DISEASES OF THE CEREBRAL MENINGES. 

ends the disease, should an effusion of blood take place, and this is a com- 
mon termination. 

The pulse during the first two or three days varies from 60° to 70°, 
while towards the end it becomes much more frequent and very full. 
During the invasion, and after the disease is fully established, especially 
if the inflammation extends to the base, the head may be drawn backwards 
and downwards. 

Ramskill 1 has called attention to the hyper-sensitiveness of the cornea, 
and I have been often impressed by another symptom, viz., the redness of 
the conjunctiva and the constant tendency to lachrymation. Vomiting 
very commonly takes place, and is always quite a suggestive symptom of 
meningeal trouble. When the disease follows otitis its onset is not so sud- 
den as when it is the result of injury, but a train of symptoms of gradual 
appearance marks the extension of the morbid process step by step, 
though in some instances rigor with sudden coma may be the first indica- 
tion of mischief. This is in most cases the purulent form. Cases of the 
idiopathic variety of pachymeningitis are quite rare, although several have 
been reported by Abercrombie and other older writers. One case related 
by the former authority may be worth mentioning. This writer also gives 
six others which originated from middle ear disease or abscesses in other 
bony cavities. These latter cases are not uncommon, if we may accept 
the experience of aurists and surgeons. Abercrombie's 2 patient, in whom 
the disease was idiopathic, died in fifteen days. The first indication was 
severe pain in the left temple, which continued for two weeks, when a 
" swelling" appeared beneath the left upper eyelid. Four days before her 
death violent convulsions took place, which were preceded by slight 
rigors. The swelling was punctured, and a considerable quantity of pus 
escaped. A probe passed into the opening came in contact with bone, and 
could be inserted for some distance, the end being in contact with the roof of 
the orbit. During previous days her condition had varied to a great degree, 
and at times she seemed to be very comfortable. On the day before her 
death -lie complained of vertical headache, became semi-comatose, and died 
in this state. Extensive discoloration, thickening, and other changes in 
the dura mater were found with adventitious membrane and pus. 

Fizeau 8 mentions a. case which closely resembles this one, and another 
quoted by Abercrombie, ami srew by Prathernon, was also of idiopathic 
origin. Abercrombie's other cases present common symptoms which were 
traced to assignable causes. Dr. Clark* has presented five cases of the 

acute form, due t<> Otitis. Dr. Bauduy* another which followed scarlet 

fever, and many of the >n\\\c kind may be found mentioned by other 
authorities. 



1 Unwell Reynolds' System of Medicine, vol. ii. page 325. 

2 Abercrombie on the Brain, page 21. 

J .Journal de M6decine, loin, ii.. New Series, page .V-'.'!. 
1 Transactions Ww Sfork Pathological Society, i s 7 G . 
■ St. Louis Clinical Record, March, L876. 




CHRONIC PACHYMENINGITIS. 37 



CHRONIC P AC I r V M en lngitis. 

Afar more interesting class of cases are those which have lasted for 
some time, have invaded the underlying membranes, ending in involve- 
ment of the cortex cerebri. The following is a fair example : — 

Symptoms John McM., age 30, of temperate habits. The patient 

was a young man of the laboring class, and was employed in a machine- 
shop at the time of the accident. Three years ago, while turning a piece 
of metal, it caught upon the end of his turning tool and flew out of the 
lathe (which was driven by steam-power), striking his head, and cutting a 
scalp wound over the upper part of the right parietal bone, lie fell un- 
conscious, and was carried to his home, remaining in the same state for 
about eight hours. After this he recovered slowly, was delirious, and evi- 
dently had had convulsions. From this period to the time when I -aw him 
his history was not very clear, but he had had convulsive paroxysms from 
time to time, and severe headache, which he complained of when lie came 
for advice. This pain was limited to the right side of the head, and prin- 
cipally centered at the injured spot. His face was quite puffed and 
swollen, and his eyes were red and watery. Pressure upon the cicatrix 
caused intense pain. His right pupil was slightly enlarged, and he com- 
plained that his vision was imperfect. Sleep was disturbed by the pain 
which would often occur in paroxysms of a very intense character. He 
complained that his left arm felt stiff, and that his fingers were cold, but 
I was unable to find any loss of power. He continued in this state for a 
year or more, and when I next saw him his speech had become slow and 
hesitating, and his face wore rather a silly expression. He then com- 
plained of some feebleness of the left arm and leg. The headache had not 
abated, and the convulsions had been much more frequent. His friend 
who came with him stated that his mind had greatly changed, that his be- 
havior was eccentric, and that he had had delusions of various kinds. I 
subsequently lost sight of him. In some features this case resembles one 
of softening. This form of chronic pachymeningitis is much more obscure 
when it is connected with syphilis. There is not only a great dispropor- 
tion between the severity of the symptoms and the extent of the morbid 
process, but symptoms of great variety may be evinced as expressions <>t' 
pachymeningitis of syphilitic origin. 1 Lagneau his 2 reports a case in which 
this inconsistency was shown. The only symptom was headache, which 
was most violent at night. Post-mortem examination revealed pachy- 
meningitis over the anterior lobes of the cerebrum, with bony plates ami 
some sclerosis of the brain-substance. There was, in addition, extensive 
perforation of the ethmoid bone. Instances are related by Gama where 
the patients had died conscious, and their meninges were found to be de- 
cidedly affected. Keyes, 8 in a, most complete ami exhaustive memoir, pre- 

1 Trans. N. Y. Path. Soc, vol. i. p. 13. 

2 Observation :>, Lagneau, Maladies Byphilitiques du Systeme nerveuz. Paris, 
I860. 

3 Syphilis of the Nervous System. New York. L870. 



38 DISEASES OF THE CEREBRAL MENINGES. 

sents a number of eases of hemiplegia which were the ultimate result of 
the meningeal inflammation, and calls attention to the pain which pre- 
cedes the hemiplegia, and which is always produced when pressure is made 
upon the cranium. A feature of the hemiplegia is the absence of any loss 
of consciousness. 

A form of syphilitic pachymeningitis may follow external syphilitic dis- 
of the cranial bones. I may illustrate the features of such an attack 
by the following case, reported by Dr. Jas. R. Wood: — 

Marie C, aged 20, was admitted to Bellevue Hospital, Jan. 7th, on ac- 
count of an eruption of two weeks' duration, which had steadily progressed 
from a few points until it had become general, being most profuse on the 
face neck, arms, and scalp. 

The eruption presented a distinct coppery hue, and was of two varieties. 
There Mere three rupitic phlegma on the head, each of which contained a 
little pus, and three or four on the shoulders and back of the same cha- 
racter. The rest were tubercular. 

She stated that, though often exposed, she had never suffered from pri- 
mary syphilis, but that there was a sore on her thigh, near the vulva, 
which appeared two weeks before the eruption. 

On examination, a simple chancre was found at the point complained 
of ; there was also a chancre of limited extent in the vagina. Soon after 
admission she was observed to have a shuffling gait, and when questioned 
about it stated that her right arm and leg " seemed to be getting weak." 
The treatment consisted in the use of the corrosive chloride of mercury in 
Huxham's tincture of bark, combined with generous diet. 

The eruption on the scalp was left undisturbed. The quantity of pus 
contained in each point was quite small, and it Avas deemed best to let 
them alone. One of them situated over the parietal bone of the left side 
was something larger than its fellows ; none of them, however, increased 
in size materially. 

There was very little improvement in the eruption,* but the hemiplegia 
steadily increased. 

Her appetite became poor, she began to have vomiting, and exhibited 
a cachectic appearance. The bichloride was necessarily discontinued, and 
mercurial vaporization substituted. 

The hemiplegia, became more complete, and her mind began to be ob- 
scured. The stupidity gradually deepened into profound coma, in which 
condition she died on the 30th. 

Autopsy There was a denudation of the parietal bone of the left side 

of the periosteum, at a point corresponding with tin; rupitic spot above 

Spokcil of. 

On removing the calvarium, the dura mater was found inflamed and 
firmly adherenl i<> the. skull, just beneath the denuded spot on the parietal 
hone and thf eruption. 

A small opening was found communicating between them, perforating 

the cranial walls, and looking very much like a, worm-hole. 

The brain :it a point corresponding with Hie inflamed dura mater pre- 
sented :i greenish appearance. 

There was also an evident fulness and fluctuation. On making an in- 
cision an abscess was discovered which contained aboul Jiij of pus. The 
<>i ber organs were beall by. 



CHRONIC PACHYMENINGITIS. 



39 



As a result of continued congestion we may have a form of pachy- 
meningitis such as follows chronic mania. I have seen this change repeat- 
edly as a secondary condition, but it must be confessed that the other 
meninges were as well affected. 

Causes. — They may be briefly enumerated as external injury, otitis, 
syphilis, alcoholism, and various acute diseases, among them rheumatism. 

Morbid Anatomy and Pathology — In the majority of cases the 
inflammation is transmitted to one or more of the important sinuses. The 
most favorable points for the extension of disease of the temporal bone are 
the narrow space between the mastoid cells of this bone and the transverse 
sinus, and that between the cavity of the tympanum and the jugular fossa ; 
and the proximity of the auditory meatus to the petrosal sinus, and the 
different canals which contain the nerves, to adjacent intra-cranial parts. 
The bony walls between these locations are of a perforated and lamellar 
character, and when attacked by caries are very apt to be destroyed. 

If the disease be of a syphilitic nature there is generally a gummatous 
deposit scattered through the tissues, and the under surface of the dura 
mater is often covered by a syphilitic exudation which can rarely be mis- 
taken. If the disease be the result of a traumatism, the membrane is seen 
to l»e thickened, opalescent, and congested. In old cases it is found to be 
closely adherent to the cranial bones, or it may contain long plates. 




Osteoma of Dura Mater (Lancereaux).— a. Bony Plate, b. Perforation, c. Falx. d. 
Slater, e. Parietal Bone. /. Scalp. 



Dura 



In this form of inflammation the morbid changes may be seen best at 
the convexity. 

Prognosis — The outlook is invariably bad. for in one variety the 
patienl is carried off in a few days, or, should the disease become chronic, 
its progressive nature musl had us to expect an ultimate implication of 

other parts, and eortieal softening or sclerosis and atrophy are probable 

terminations. 



40 DISEASES OF THE CEREBRAL MENINGES. 

Treatment Treatment should be directed in the beginning to the 

cause, and if there be otitis, a free escape of pus should be provided for, 
and counter-irritants, topical applications, and leeches should be em- 
ployed. If the pachymeningitis be attended by much pain, cold to the 
head and free administration of the bromides will be of service. The 
leeches may be applied to the tragus of the ear, or to the mucous mem- 
brane of the nostril. 

CHRONIC PACHYMENINGITIS WITH HEMATOMA. 

It has been the custom, among certain writers lately, to speak of hema- 
toma as an inevitable result of pachymeningitis. This, I think, is a mis- 
take, for the production of blood-cysts is not the invariable rule. If, 
however, the thickening ot the dura mater is excessive, there may be a 
gradual destructive process, which will be described when we come to 
speak of the morbid anatomy and pathology of the affection. 

The disease may begin as I have already described, and may advance 
to a certain point before the grave symptoms which indicate rupture and 
consequent meningeal hemorrhage are expressed. These may vary in 
intensity in proportion to the extent of the effusion, which may be even 
so great as to produce sudden death, but such an early result is excep- 
tional. The course of the disease is generally more gradual, and there is 
at first an initial hemorrhage of slight extent, which is followed in a great 
number of cases by two or three others. In some respects this effusion re- 
sembles cerebral hemorrhage in the production of acute symptoms, but 
tUfcy are nearly always less profound ; and it is not so frequently followed 
by complete paralysis. 

Symptoms The early symptoms of pachymeningitis which I have 

enumerated are those preceding the immediate evidences of the effusion. 
They may be reinforced by loss of memory and stupidity, and after a few 
months there maybe a transitory loss of consciousness and incomplete 
hemiplegia which is characterized by much hyperaesthesia. 

The phenomena of the attack are thus described by Huguenin : l ''Se- 
vere headache just before the attack ; after loss of consciousness lias 
occurred, contracted pupils, not reacting; in a few cases, paralysis of the 
facial aerve, on the side opposite to that of the hematoma ; sometimes 

hemiplegia. These latter symptoms only occur in one-sided hemorrhages. 

A marked change in the color of the face is another of the symptoms re- 
ported. At the commencement of the attack, which is usually sudden, 
the face becomes flushed ; the pulse is full and rapid, but soon grows sma.ll 
and irregular, and pallor succeeds the Hushing. In some cases the pulse 
is slow; in others there is an increase in rapidity, continuing up to the 
time of death. Contractures of the extremities, and slight transitory 
twitchings, were present in a few cases." 



1 Ziemssen, Cyclopaedia of the Pract. of Med., translation, vol. xii. page 109. 



CHRONIC PACHYMENINGITIS. 41 

Instead of hemiplegia there may be one-sided convulsions, bnt these 
depend very much on the degree of pressure exerted upon the cortex- 
cerebri. The condition, Strang*' fco Bay, is sometimes arrested after an 
indefinite period, and there is a return to the normal state, but traumatic 
hematoma is usually fatal. 

Schuhberg 1 assents to the view held by Herschl, Virchow, and Cruveil- 
hier, that hematoma is always the result of fibrinous inflammation, and 
believes that the prognosis is grave. In this paper he considers the dura- 
tion of a fatal case to be about one month. 

Causes Hematoma is a disease of adult life, and twenty-two per 

cent, of the cases collected by Huguenin were between the seventieth and 
eightieth years, and Durand-Fardel found that 77.4 per cent, of all cases 
were men, and 22. G per cent, were women. As causes may be mentioned 
various cachectic and other diseases, among them Blight's disease, scurvy, 
syphilis, typhus fever, rheumatism, smallpox and scarlatina, alcoholism and 
sunstroke, or any condition which is conducive to continued hypenvmia of 
the dura mater. 

Morbid Anatomy and Pathology The process involved in the 

production of hematoma is an exceedingly complicated one, consisting 
in the production of new vessels and new layers of fibrine due to th< 
travasation of blood. The first layer of this new tissue-formation takes 
place in contact with the arachnoid, and ultimately others form and he- 
come organized. The formation of the blood-cyst is due to the rupture 
of one of the new vessels, and the extravasation becomes surrounded by a 
layer of tissue which may be so firm as to preserve the cyst contents un- 
changed. This is particularly the case in the smaller cysts. The skull is 
sometimes found to be thin as seen by Hyrtl, 2 but this is not common, and 
some writers, among them Textor 3 and Rokjtansky, 4 consider that the 
reverse is to be seen in a greater number of cases. I may briefly enume- 
rate the post-mortem appearances as follows : Beneath the dura mater may 
be found a layer of coagulum which contains fibrinous shreds binding it to 
the membrane itself. If the case be of long duration several layers of 
false membrane containing bloodvessels are to be found attached to the 
dura, and the late formations may be distinguished from those of early 
origin. Between these layers it is not unusual to find the results of inter- 
stitial hemorrhages which exist as blood-clots in different styles of organi- 
zation. The thickening of the dura mater is thus described by 1 
"In the non-purulent form of the new formation, the result of inflamma- 
tion becomes very quickly the seat of vessels and i< composed o\' several 
layers; those nearest the dura mater being composed of compact lustrous 
Connective tissue fibres almOSl as i\r\\>o as the dura, mater itself, whilst the 
layer further removed from the dura mater is rich in cells with small 

1 Schmidt's Jahresbericht, vol. 104, pp. 164, 165. 

2 Hyrtl, sec Ziemssen's Encyl., vol. xii. Am. Tran., Art. •• Meningitis." 

3 Textor, WUrzburg Verhandlung, vii. : 
i Rokitansky, quoted by Huguenin. 



42 DISEASES OF THE CEREBRAL MENINGES. 

narrow vessels, and the layer nearest the arachnoid, often firmly uniting 
the arachnoid to the dura mater, is remarkable for very large capilla- 
ries." 

The size of the hematoma may vary from that of a small bean to that 
of an orange, and in one case, the autopsy of which was made by Dr. 
Huber of the Colored Home, the blood-cyst covered one entire side of the 
brain, and was fully an inch in depth. The patient was under the care of 
Dr. Whitall, who kindly contributes the following notes : — 

P. B., 60, widower, N. Y. ; mulatto; father, mother, and one brother 
died of phthisis. The patient has been intemperate, but now drinks only 
in moderation. He denies venereal disease; twenty-five years ago he 
had smallpox, and has since had intermittent fever and cholera. His 
trouble dated from an injury seven years ago. He was thrown from a 
hay-truck to the ground, falling upon his head, and causing blood to flow 
from his left ear; but he was able to walk to his home, one mile distant. 
He seems to have received no very serious injury, if we may judge from 
the immediate symptoms. Since the fall he has been troubled with head- 
ache off and on, increased by approaching a fire. He cannot appreciate 
the ticking of a watch pressed to his left ear. About a fortnight ago he 
had a chill, fever, and cough, some pain in back, with soreness around 
the whole gluteal region. Urination was slow, disturbed, and at one time 
he was unable to pass water; at another it would be too free; has been 
growing weaker since. 

June 15, 1874. On admission patient was confined to bed; owing to 
apparent weakness in lumbar region he was unable to stand. In a few 
days he begat) to improve under the administration of iodide of potash. 
Walks with a staggering gait, and cannot follow a straight line. On 
closure of eyes does not have a tendency to fall. Heavy expression of 
countenance. No diminution in acuteness of sensibility can be discovered 
over any portion of the body. Had incontinence of urine on admission; 
is nol so troubled at present time. Can walk about the ward; at times 
can dress without assistance. To-day complains of frontal headache; 
sleeps very soundly, with stertorous breathing. Appetite good; bowels 
constipated. 

2 I///. Staggering ga.it, and inability to walk in a straight line, still pre- 
Bent. If he (doses his eves while standing, there is a tendency (which by 
an effort he can overcome) to fall backward. Complains of pain on right 

Bide of head and face; sleeps most of the day in a, chair; a! night snores 
loudly. Bowels constipated. Nocturnal incontinence of urine exists. 

Feb. 6, L875. To-day, while patient was sitting in a, chair, he had a 
convulsion, and then became comatose. Urine albuminous. Ordered ol. 
tiglii rti'w , after the action of which he appeared much better. 

[5th. Very little change in patient's general condition since above 
note. Is still apathetic, and complains of pain in bead, on right, 
Bide especially. There is -till righl facial paralysis, with somewhal di- 
minished sensibility in this region. The tongue do\ iates, if any, to the 
right. Pupils normal in size and reaction. No notable change in hear- 
ing. No h>-- of motion, though the righl aruj and leg are weaker than 
the left. The lower limbs (left more readily {han right) can be drawn 
upwards, and extended with little trouble. He is unable to walk or stand 
without being supported, as the right leg gives way; complains of con- 



CHRONIC PACHYMENINGITIS. 43 

siderablc pain in the upper portion of the limb. Has occasional involun- 
tary passages of urine and feces; as a general thing, however, the bowels 
are confined; urine evacuated with considerable force. 

March 19. Appears to be losing strength very rapidly. Will no! an- 
swer when spoken to. Temp. 99£°. 

21st. Died about 9 P.M. comatose. 

Autopsy, 3G hours post-mortem Rigor mortis marked. Body slightly 

emaciated. 

The dura mater was found very firmly adherent to the calvarium to the 
right of the longitudinal sinus, and over a considerable portion of the con- 
vexity. After removing the dura mater, the pia mater on the left side 
was discovered to be unusually dry and somewhat congested, with here and 
there slight patches of lymph. The convolutions throughout this hemi- 
sphere were greatly flattened, and the sulci nearly obliterated. In the 
right cranial cavity a large haematoma existed. The tumor pear-shaped, 
with larger extremity anteriorly, extended from the anterior portion of 
the second frontal convolution to the posterior portion of the second tem- 
poral, and from within an inch of longitudinal fissure to junction of lateral 
portion with base of skull. 

The right hemisphere was correspondingly compressed downwards, 
backwards, and to the left. The depression corresponded to the shape of 
the tumor, and was so situated that the greatest amount of pressure came 
upon the left lateral ventricle. The dimensions of this growth were as 
follows: 6|- inches antero-posteriorly ; 4 inches vertically in greatest diam- 
eter ; and about 2 inches in thickness. 

In addition to the haematoma, a serous cyst (about the size of a hickory- 
nut), evidently originating from an old hemorrhage in the subjacent brain 
structure, the cicatrice of which still remains, was seen beneath the an- 
terior lobe. Back of this another cyst, the walls of which were chiefly 
composed of softened brain tissue, was discovered, which, upon closer 
investigation, was ascertained to be continuous with the right Literal ven- 
tricle through the middle cornua. The right ventricle was greatly dis- 
tended by scrum, while comparatively little could be detected in the left. 

In the left ophthalmic artery a long, slender clot, partly dark and 
partly translucent and yellowish, existed. No thrombi were noticed in 
the slightly atheromatous arteries at the base of the brain. 

No connection existed between the pia mater and the haematoma; the 
relations between it and the dura mater were so intimate as to require 
dissection before a separation was possible. 

The petrous portion of the right temporal bone was considerably larger 
than the left, and, upon section, proved to be much more porous. No 
other abnormalities were present; no evidence of fracture at the base. 

The way in Avhich the tumor, though situated on the right side of the 
brain, pressed upon the left, ventricle, explained the symptoms which, 
during lite, pointed to an involvement of I he left side; and also offered an 

explanation as to the manner in which the fluid was forced through the 
middle cornua of the right ventricle. 

Heart Very flabby; cavities dilated, and filled with dark coagula. 

Aortic valves were slightly thickened, and the artery was atheromatous. 
Mitral valves thickened. 

Lungs The right was firmly bound to chest; Veiysoff and congested. 

The sui-face was studded with pigment. 



44 DISEASES OP THE CEREBRAL MENINGES. 

The left had also become adherent to parietes, and, at the apex, a few 
softened, cheesy points were discovered. 

Spleen — Enlarged and congested. 

Llrer. — Normal. 

Kidneys. — Cortex somewhat thicker than usual; both organs were 
waxy. 

Weight of the organs. — Heart, 10 oz. ; spleen, 7 oz. ; liver, 55 oz. ; 
right lung, 29 oz. ; left lung, 18 oz. ; right kidney, G oz. ; left kidney, 5 oz. 

Prognosis The existence of a blood tumor of this kind is not 

always a serious matter. Even after two or three extravasations have 
occurred, a retrogressive course takes place; but this is rare. Griesinger 1 
reports a case in which partial recovery has taken place; and in 187G the 
patient was still alive, and presented slight evidences of his former serious 
trouble. This termination of the disease is exceptional, however. 

Treatment. — What has been said in regard to the management of 
uncomplicated pachymeningitis is applicable in this disease ; and, in addi- 
tion, venesection has been advocated by more than one authority. It should 
be employed during the comatose stage which marks the occurrence of an 
effusion, and at the same time a drastic cathartic will be found to be of 
excellent service. High living and excessive use of tobacco and alcohol 
are to be interdicted, and iodide of potassium may be given with the idea 
of producing absorption of the new growth. 



ACUTE CEREBRAL MENINGITIS. 

The term meningitis has been applied, clinically speaking, to that form 
of inflammation which involves chiefly the arachnoid and pia mater, and in 
its acute form may be expressed by the following grave and alarming 
symptoms : — 

Symptoms. — These may be divided in regard to their appearance 
into three stages: 1st. The stage of excitement or irritation; 2. The 
stage of delirium ; 3d. The stage of stupor. 

An hypothetical case maybe presented. The patient complains of a 
-light headache, which increases towards the end of the first, twenty-four 
hours. It may not be attended by much annoyance, and he is usually able 
to attend to his daily duties. But during the succeeding six or eight 
hour.- it may become greatly aggravated, and is attended by restlessness, 
flushing of the cheeks, throbbing of the temporal vessels, and general dis- 
comfort. After a lew hours there may he slight rigors or a. severe chill, 
which is often mistaken lor ague; and the rapid elevation of temperature, 
and hard, bounding pulse may strengthen the suspicion. The headache 
continues, and is -till not eon lined to any particular locality, but is so intense 
thai the patient seeks his bed, where he may lie, moaning, sighing, or toss- 
ing restlessly to and fro. The muscles of the legs may twitch, and the 

« Arciiiv der Heilkunde, 1862. 



ACUTE CEREBRAL MENINGITIS. 45 

least noise, such as the creaking of a door, invariably irritates and startles 
the invalid; bright lights distress him, and he closes his eyes instinctively. 
He keeps his hands over his cars so that lie may not hear noises in tin- 
room, or firmly presses his aching temples. There maybe vomiting which 
is not dependent upon the condition of the stomach, is not attended by 
retelling, and occurs whether the stomach be empty or full. If the patient 
be a child, there are generally convulsions of a very violent character. 
These constitute the first stage. 

Active delirium usually appears during the first two days, and continues 
through the greater part of the second stage. The patient screams in an 
agonizing manner, and alarms those who may be with him, adding greatly 
to the distressing character of his sufferings. The delirium now begins to 
subside, or may be supplanted by coma. The temperature becomes lower, 
and the pulse loses much of its force and rapidity. The head is hot, and 
the respiration becomes irregular and sighing. The bowels, which were 
constipated in the first stage, still continue so, and the tongue is coated 
with a dirty-white fur. There may be convulsions at this time which 
Ramskill 1 says may precipitately throw the patient into the third stage, 
which is one of collapse. This stage may resemble that of advanced ty- 
phoid. Sordes on the teeth, pinched features, dark circles about the 
fluttering pulse, great prostration with loss of muscular power, dilated 
pupils, stertorous breathing, and the unconscious passage of feces and 
itrine, are all forerunners of death. Should the force of the inflammation 
be exerted at the base, the symptoms are much more violent, and para- 
lyses of cranial nerves are not uncommon. 

Causes In considering the predisposing causes of acute meningitis 

it will be well to inquire what are the influences of sex and age. The re- 
ports of the New York Board of Health show that during the years 1867, 
18G8, 1870, 1871, 1872, and 1873 there were 4321 deaths from menin- 
gitis in the city of New York, 250G of whom were males, and 1<S 1.1 females : 
3434 were children under 5 years; of these 1873 were males, and 1561 
females. It will therefore be seen that males are more often affected than 
the other sex, and that the large proportion of cases occur among children. 

Rilliet and Barthez take an opposite view of the matter, and consider 
the disease to exist more frequently after the fifth year. My own expe- 
rience and the Health Board's statistics lead me to think that after this 
period of early life, the adult eases are comprised in the interval between 
the twentieth and fiftieth years, and I am unable to find the records of many 
Cases after (he sixtieth year, and am therefore disposed to believe that the 
disease is pare after thai time. Various predisposing causes give rise to the 
affection, and none, I think, plays a more important part in the production 
of the adult variety than continued dram-drinking and hard work in warm 
places. Over-use of the mental powers, and various disorders, sueh as 

Byphilis and gout, are favorable to its development. 

Croupous pneumonia, acute rheumatism, diphtheria, extension of dis- 

1 Article in Reynolds' System of Medicine, p. 369, vol. ii. 



4G DISEASES OF THE CEREBRAL MENINGES. 

ease from the tympanic cavity, blows upon the head, and sudden changes 
of temperature of any kind, are the direct causes of acute meningitis. In 
one of my cases the disease was the result of a sea-bath. The patient, 
after bathing, sat for some time with uncovered head upon the beach ex- 
posed to the heat of a noonday sun. Haeddeus 1 reports a case of this 
disease which resulted from typhoid fever. 

Diagnosis. — Acute cerebral meningitis may be mistaken or con- 
founded with cerebritis, typhoid fever, or delirium tremens. The deli- 
rium, headache, and disorders of motility are much less marked in cerebritis 
than in acute meningitis, and it must be remembered that the pulse in the 
latter disease is much more rapid and full, and the temperature much 
higher. 

Typhoid fever is symptomatized by elevation of evening temperature, 
diarrhoea, abdominal tenderness and tympanitis, muttering delirium, and 
the presence of petechia?. Delirium tremens may be occasionally con- 
founded with the disease under discussion, but it must be remembered 
that the history of alcoholism — peculiar delusions and alcoholic delirium, 
the absence of headache and the condition of the skin, are all evidences of 
delirium tremens, which are not to be mistaken. 

Pathology and Morbid Anatomy When the pia mater and 

arachnoid become the seat of inflammation, we may roughly group the 
lesions and consequent symptoms into two classes, one indicative of basal 
trouble and the other of vertical. In the former, cranial nerve-trunks 
will be injured or diseased ; while in the latter, the investing membranes 
<>f the cerebrum will be the seat of morbid action, and the functions of the 
cortex must be consequently destroyed, so that the symptoms will be more 
of a psychical character than when the base is involved. 

The recent investigations and contributed cases of Landouzy, 3 of which 
104 are presented by this author, demonstrate the connection between cer- 
tain symptoms and lesions of the description to be hereafter mentioned, in- 
volving those portions of the cortex containing the centres of llitzig 3 and 
Fritsch. These prove very clearly that violence of the inflammatory pro- 
cess in certain places may be attended by certain paralyses or contrae- 
fcions of Limbs which are innervated from these centres. A case which 
recently came under my observation is one of this kind, and possesses 
great pathological interest. 

B. B., aged thirty-six, horn in Ireland, by occupation ;i blacksmith, is 
;i -lout, well-made man of nervous temperament, and up to the commence- 
ment of his presenl trouble had enjoyed uninterrupted good health. He 
has nol had Byphilis, and his habits have been good. His mother and 
father are dead, th<' former having died of old age and the latter of phthi- 
sis. There is no family history of insanity, epilepsy, paralysis, nor of any 

1 Berliner Klin. Woch. L869, p. 564. 
Contribution aT' etude dea Convulsions el Paralysis lie"esaux Meningo-enceph- 
litis fronto-pari6tales. Paris, L876. 
i Reichert and l>n Boie Reymond's Archives, L870, Heft 8. 



ACUTE CEREBRAL MENINGITIS. 47 

organic nervous trouble whatever. Ten years ago, while working upon a 
fire-escape, he fell to the ground, two Btories below, Btriking upon his head 
and shoulder, lie was taken up unconscious, and remained so for four- 
teen hours. The only injuries he received were two severe scalp-wounds, 
one of which from its Blowness in healing must have been attended by 
some bone injury, for he was unable to resume work until three months 
later. He says that purulent accumulations took place, and that "the 
doctor lanced them." Two cicatrices are now visible, one of which i- 
about an inch and a half long, and is situated on the hit -ide of the head 
and covers a depression about three-quarters of an inch in diameter and 
one-quarter of an inch in depth, the centre of which is about one and one- 
half inches below the median line, five inches above the left ear, and four 
and three-quarters inches above the centre of the left supra-orbital arch. 
This is the only depression visible, and the injury on the right side was 
apparently very superficial. 

He gives no history of serious head symptoms, and when he resumed 
work was in good condition, there being no paralysis. About three months 
later he noticed a tremulousness of the fingers of the rigid hand, and 
afterwards of the arm of the same side. There was no pain nor los> of 
power, but simply a marked tremor whenever he attempted to do any- 
thing. This difficulty increased to such an extent that he was obliged to 
resign his position as first-class workman, and become a helper, using his 
other arm to work the bellows. About six months after this the tremor 
affected the right leg, and he was obliged to leave his work. 

Present Condition The patient does not complain of head symptoms, 

except a slight hyperesthesia of the right side of the face, of short dura- 
tion. Vision normal ; fundus of either eye presents no abnormal appear- 
ances ; pupils respond well to light, and are of equal size. Hearing 
unaffected. No tremor of face or tongue, speech unembarrassed, memory 
good, and no intellectual trouble whatever. He has never had headache. 

Upper Extremities Left side unaffected. The right hand and arm 

are perfectly quiet during inaction, but when the most simple voluntary 
act is attempted they become agitated by a fine rhythmical tremor, which 
becomes more marked as the accomplishment of the act requires greater 
nicety of coordination. When he is asked to carry a glass of water to his 
mouth, he spasmodically grasps the vessel and carries it upward, the elbow 
being raised, the tremor meanwhile increasing until the mouth is reached, 
when the movements become so violent that he is unable to place the rim 
of the glass between his lips. Certain motions are almost entirely unat- 
tended by tremor. He can extend the arm and hand, or can hold them 
rigidly upright, and is able to pronate the hand, but movements of flexion 
are attended by increased violence of the tremor. Tactile sensation is 
somewhat impaired, but susceptibility to painful impressions is not dimin- 
ished. There is absolutely no loss of muscular power, no atrophy of the 
hand or arm, the thenar eminences being covered by firm cushions, and 
the interosseous spaces being well filled. 

Loire,- Extremities The left leg, like the arm, is in no way affected. 

The right leg, however, is agitated by muscular tremor when he attempts 
to use it, or approximates it with its fellow, as in standing erect. There 
is no loss of muscular power, but some anaesthesia, the patient being 

unable at any place to distinguish two points of the a->thesionieter. Unless 
they are separated at hast eight centimetres. 

When he stands with his eves closed he is "groggy," bm doc- not tall. 



48 DISEASES OF THE CEREBRAL MENINGES. 

He can stand upon the right foot alone, but not upon the left. When he 
walks, the right heel is brought down first, so that the heel of the shoe is 
much worn, lie has some plantar formication and coldness of the foot. 
He has suffered from pains of a pseudo-neuralgic nature in the right 
shoulder and right thigh, which were centrifugal, as well as some pains 
which darted from the heel up the inner side of the leg. The pains in the 
upper extremity are not so frequent as they were a year ago. There has 
been no history of body-constricting band, pain in the back, or vesical 
trouble of any description, but for the past five years he has been consti- 
pated and obliged to take purgatives. There are no contractions whatever. 

The peculiarities of this case seem to be the unilateral tremor (not dis- 
orderly movements) excited by voluntary exertion, its predominance in 
flexion, while certain movements of extension are almost unattended by 
any embarrassment, the absence of muscular weakness, contractions, or 
atrophy, and the evident dependence of the trouble upon a localized cere- 
bral injury of the opposite side, which probably resulted from the fall. 

1 am unable to arrive at any conclusion which would lead me to con- 
sider the symptoms due to cerebro-spinal sclerosis, or one-sided posterior 
spinal sclerosis, if the latter anomalous condition could exist. The utter 
absence of loss of power and permanent contraction of the affected limbs, 
and the non-extension of the affection to those of the other side of the 
body within ten years, are sufficient to invalidate such a diagnosis. 

The non-occurrence of convulsions and other symptoms of cerebral 
tumor renders this as a cause of the tremor quite improbable. 

Of course the assumption that this patient's symptoms are due to some 
irritative meningeal or cortical lesion must be based upon purely theoreti- 
cal grounds, but the features of the case convince me that such a condition 
of affairs is by no means improbable. If we take the trouble to consult 
tin' charts of Hitzig and Ferrier, we shall find that they have assigned a 
cortical region which is "situated on the ascending frontal, just behind 
the upper end of the posterior extremity of the middle frontal convolu- 
tion." which "is the centre for the movements of the hand and forearm 
in which the biceps is particularly engaged, namely, supination of the 
hand and flexion of the forearm." 1 Again, if we consult the admirable 
article of Turner, 2 we shall find very useful hints which will enable us to 
lay out the exterior of the cranium into regions corresponding with the 
convolutions beneath. One of these areas, which has been called the 
upper antero-parietal space, includes the ascending parietal and ascending 
frontal convolutions, and an injury at the point I have located in describing 
this case would be just over the centre, which, when experimentally irri- 
tated, produces movements of flexion and supination. 

It is quite reasonable to suppose that this irritation occurring with voli- 
tional movements is due to a natural increase in the blood pressure during 
mental activity, a consequent increase in cerebral volume, and a, resulting 
meningeal contact with the depressed portion of bone, which probabrj 

does not impinge upon the cranial contents at ordinary times. 

In the majority of Cases the inllammal ion begins at the base and extends 

upward-. The temporal lobe may often b* its starting-point, while in 

«i " 

1 Function! of the Brain, page 807. 
Journal of Anatomy and Physiology, vols, xiii., kiv., November, is::;. May, 
1874. 



ACUTE CEREBRAL MENINGITIS. 49 

other varieties the meninges covering the cerebellum may alone be in- 
volved. The appearance of the cranial contents cannot be mistaken, the 
membranes are red, hyperaemic and attached to cadi other, and the arach- 
noid cavity contains a considerable quantity of serum. The fluid in the 
ventricles is increased and may contain pus, and the choroid plexuses 
are found to be turgescent and enlarged. It may be stated upon the au- 
thority of Huguenin 1 that in some cases the intra-ventricular fluid is puru- 
lent on one side, while it may be simply serous on the other. In a_ 
vated cases the quantity of pus may be considerable, and if the meningitis 
be of the basilar form the pia mater of the base will exhibit extensive 
purulent infiltration. The ependyma of the ventricles may be thick- 
ened, and contains yellowish deposits. In cases due to traumatism, or ex- 
tension of other diseases, there may be found evidences of caries or fracture. 
The cortex in nearly every case of meningitis of the convexity is found to 
have undergone decided softening, and when the meninges are removed, 
some of the superficial brain -substance is carried with them. 

Prognosis. — We should always hesitate in expressing our opinion as 
to the course of the disease, although so few cases get well that it is almost 
safe to say that our patient cannot recover. If the patient improves after 
the first week, we may consider the prognosis much more hopeful, but 
there are often deceitful lulls which may mislead the medical attendant. 
If active treatment produces beneficial results, his chances are better, while 
any evidence of ocular trouble, and consequently basal involvement, lessens 
the patient's chances materially. Should the disease result from extension 
of inflammation of the temporal bone, the prognosis is also grave. Death 
may occur in four or five days, or even in a shorter time, but the duration 
of the disease may extend to the tenth day. 

Treatment. — Two indications are to be met promptly: one the ab- 
straction of blood ; the other, cold to the head. When the delirium is 
furious, temporal vessels swollen, and the pulse hard and bounding, ab- 
straction of blood from the arm is to be immediately resorted to. A sug- 
gestion made by Holland many years ago is one of value, notwithstanding 
the fact, that it has been almost forgotten and generally disregarded. I 
allude to the application of leeches to the hemorrhoidal veins; to use his 
words : " I know of no mode in which a given quantity of blood can be 
removed with equal effect in cases where it is required." 8 Cold to the 
scalp either by ice-bags, or by a bladder filled with pounded ice, or an 
arrangement of rubber tubes, should be employed, and will be found to 
very speedily relieve the pain. Accepting a hint from Dr. Chamberlain, 
of this city, 1 have had constructed and successfully used an apparatus Buch 
as I will describe. It consists of a long piece of rubber tubing wound upon 
itself and securely held in its spiral form by tape, forming a skullcap. The 
upper end is connected with an ice-cooler or a cold water tap. should there 
be one in the apartment ; and the other is fitted with a. Stopcock BO that 

1 Ziemssen's Encyclopaedia, vol. \ii., translation. 

2 Quoted by Solly. The Human Brain, etc., page :i.">;i. 
4 



50 DISEASES OF THE CEREBRAL MENINGES. 

the discharge of water may be regulated. By this means the patient's 
head can be kept cool and his bed dry and comfortable, an impossible 
state of affairs when the douche is used. Iodide of potassium in large 
doses has been given with excellent effect, and its efficacy in this disease 
lias been praised by Flint, Alonzo Clark, and others. Aconite, ergot, and 
the bromides are all efficient remedies in depressing the pulse and quelling 
the delirium; and elaterium (F. 22), saline cathartics, or the old combina- 
tion of salts and senna (F. 41) may be of service. Blisters applied behind 
the cars and to the neck are excellent adjuvants. Should the patient's 
strength be reduced, as is the case in the later stages, the free use of 
stimulants, nourishing food, such as milk, egg-nog, beef-broths, and nutri- 
tious but digestible food, are of great importance. In the other forms 
presently to be alluded to, we should be governed by the existence of rheu- 
matism, or the advanced age of the patient, and for the former prescribe 
alkalies, colchicum, and other remedies of the same nature, and for the latter 
a generous diet and a liberal use of stimulants. (F. 17, F. 45.) 



RHEUMATIC MENINGITIS. 

A form of inflammation of the meninges may be connected with, or 
occur during the course of acute articular rheumatism, or again it maybe 
found without any coexisting joint trouble. 

Trousseau 1 has described three forms of cerebral rheumatism. One of 
these he calls apoplectic, and it is symptomatized by coma without paraly- 
sis : a second form, first described by Gosset, is that in which delirium 
is followed by coma ; and there is a third in which delirium makes 
it< appearance in the course of inflammatory rheumatism. Its co- 
existence with joint-trouble is by no means the rule, though the majority 
of cases reported have been of this character. Posner 2 reports a case in 
which the inflammation left the joints and attacked the meninges, rain 
in the head, delirium, and slow pulse were the prominent features of the 
patient's illness, and recovery took place in about two weeks. The 
symptoms of an attack of metastatic rheumatic meningitis are these: 
Either during an attack of acute rheumatism, or afterwards, the patient 
may become dull and stupid, and delirium makes its appearance. This 
delirium is of a, violent character, and during its existence the patient 
may have delusions and hallucinations of sight and hearing. In a case 
reported by Meznet 8 the delusions of persecution were a prominent fea- 
ture, but there is no regularity in their mode of expression. There is 
usually hiit ;i slighl rise of temperature, though it may sometimes attain 

an elevation <>f 106 , or thereabouts, and the pulse at the same time be- 
comes very rapid and lull. Headache of a severe variety, such as I have 

described when Bpeaking of tl ther forms of acute meningitis, may be 

■» 

1 Rheumatismus Cerebralis, Schmidt's Jahresbericht, vol. 118, p. 2$. 
1 Rncephalopathia Rheumatics, [bid., vol. L04, p. 167. 
1 Archivea Ge*i grales, .June, 1856. 



RHEUMATIC MENINGITIS. 51 

present throughout the illness, and, sifter several days, clioreaform move- 
ments may occur, and with their advent the delirium, which was before 
inconstant, now becomes continuous. These choreaform movements are 
such as a nervous embarrassed person would make in health when sud- 
denly disconcerted. There is an uneasy opening and closing of the fii . . 
and the arm is jerked backwards and forwards. The patient now finds 
considerable difficulty in swallowing, portions of food remaining in the 
mouth for some time. Great prostration and collapse may Supervene, and 
the patient dies in a comatose state, or, on the other hand, there may be 
slow recovery, the mental symptoms being the last to subside. 

Vomiting and early headache, which are so characteristic of the other 
forms of meningitis, are absent. Recovery is rare, and of thirty-nine 
cases reported by Vigla, 1 thirty terminated fatally. Should the patient 
survive, he is very apt to become insane, the variety of such mental 
trouble bein£ chronic mania. Huguenin 2 considers that the connection of 
meningitis with rheumatism is threefold : — 

" a. Endocarditis is the connecting link, so that the combination is 
rheumatism, ulcerative endocarditis, meningitis. 

" b. Purulent inflammations of the serous membranes form the connect- 
ing link, endocarditis being present or not, as may be. In this case puru- 
lent meningitis is secondary to purulent inflammation of the serous mem- 
branes ; this is very rare, and the exact connection is unknown. (An 
observation of our own, in which the coincidence was striking, but the 
manner of transmission obscure.) 

" c. Meningitis complicates rheumatism without there being any puru- 
lent deposits in the body, or any affection of heart ; the connection here is 
also obscure." 

Da Costa 3 is inclined to refer the brain symptoms in cerebral rheuma- 
tism to two agencies, the first of which is a circulation of vitiated blood, 
and the second is the disturbance of cerebral circulation dependent upon 
the plugging of small arteries by fine embola, and consequently considers 
cerebral rheumatism to be a disease which is not essentially an inflamma- 
tion of the cerebral meninges. 

A case of rheumatic meningitis which recovered under the use of cold 
baths — and was treated by M. Fereol,' 4 of Paris — is the following: — 

The patient was thirty-four years old, of quiet and temperate habits. 
who was suffering from acute articular rheumatism. He was treated at 
first with emetics, sulphate of quinine, and colchicum, but in live days he 
was seized with delirium, agitation, and dyspnoea, and at the same time 
the pains in the joints disappeared. The temperature of the body rose to 
forty degrees (Centigrade), and leeches, calomel, and bromide of potas- 
sium were given without success. 'The temperature rose further to forty- 
placed on the scalp, and digitalis was 



1 A.-trs de la Soc, Med. des Hdpitaux de Paris, 1865, 3me fas. 

2 Op. cit., p. 624, 

• ? American Journal Med. Sciences. Jan. 1875. 

4 Bull. (icn. deThfirap., Mar. 80, 1875. Med. News, 1875. 



52 DISEASES OF THE CEREBRAL MENINGES. 

given. There was then a little more rest, but the aspect was typhous, 
with stupor and continuous sub-delirium ; sleeplessness, agitation of the 
muscles, subsultus tendinum, dry tongue, etc. After some consultation 
with other physicians it was determined to try the effects of cold baths as 
the only remaining resource. This plan was pursued for a whole week, 
the patient remaining under close observation the whole of the time, and 
the thermometer being almost fixed under the axilla. As soon as the 
temperature rose to 39.5° the patient was plunged into a cold bath. From 
the 25th of February to the 3d of March sixteen baths were administered 
at a temperature varying from twenty-one to twenty-five degrees (Centi- 
grade), and the duration of each bath was twenty minutes on the average. 
The patient always raised the temperature of the water from one to two 
degrees, and, on leaving the bath, his own temperature fell to thirty-six 
degrees. After several fluctuations and much anxiety on the part of the 
medical attendants, the patient eventually recovered completely. 

MENINGITIS OF THE AGED. 

According to Prus, 1 meningitis of the aged rarely presents the same 
symptoms as do the forms of early or middle life. In the morning the 
old man or woman is stupid, but conscious ; speech is thick, and there is 
general headache and moderate fever. The warmth of the body is nearly 
normal, except at the head, where it is markedly increased. In the even- 
ing it is elevated. 

The eyes are injected, and there is low delirium. Incoherency and 
restlessness, during the night, and an uneasiness which is expressed by 
walking about the house and going from one bed to the other, are mani- 
festations which are characteristic. 2 If the disease is to end fatally, the 
patient becomes comatose, and dies within a week, or twenty days at the 
longest, from the commencement of the disease. These patients very 
often suffer for some time before the actual attack, when there may be 
partial paralysis, slight wandering of the mind, and insomnia. The gene- 
ral indications for treatment of the other forms are applicable in these 
cases. 



ACUTE GRANULAR (TUBERCULAR) MENINGITIS. 

Dr. Robert Whytt 8 was the first to describe this disease, and so satisfac- 
torily <li<l lie do so, that even after a hundred years there is very little to 
;| <1<| to lii- accurate description. We shall have to study (ho disease as 

occurring in two different ways. It may be primary, and have a doubt- 
ful tubercular character, or may occur in connection with some thoracic 



1 Quoted l>\ ( Srisolle, vol. i. p. 480. 

1 RamekiH speaks of the eccentric behavior or these patients, who may use the 
spittoon instead of the chamber pot, or commit o$er violations of decency. In 
one case which came to my knowledge, the patienl urinated against the bed-post, 
and wen! aboul the house with his browsers unbuttoned. 
Works of Dr, Whytt, Edinburgh, 1768. 



ACUTE GRANULAR MENINGITIS. 53 

or abdominal disease, and like the other forms of meningitis, may be con- 
fined to the base or convexity. 

Symptoms Though many of the symptoms are the same, there are 

a few general points of difference, which are the following : — 

Predominant Symptoms. 

BASAL. VERTICAL. 

Vomiting, constipation, infrequent or Convulsions with intervals occupied 

irregular pulse, unequal pupils, stra- by tremor, twitching of limbs and nms- 
bismus. cles of face, turning of thumbs in on 

palms, clenching of fists, frequent pulse. 

"When the base is involved, the symptoms may be grouped in three 
stages, which run their course in from four to twenty-one days. The 
child may be puny and delicate. He may lose flesh and complain of 
headache. His skin may be white and waxy, and there may be a ten- 
dency to flushed cheeks, loss of appetite, and capriciousness about food, 
and at night he does not sleep soundly, but starts and cries out. I have 
known children to seek the companionship of some other member of the 
family, fearing to be left alone. The child may moan in its sleep, grind- 
ing his teeth and lying with eyes widely opened. During the day he is 
disinclined to play, and seeks some quiet place in which to fall asleep or 
remain by himself. Study is irksome, and so are all other forms of men- 
tal application. Irritable or languid, he attracts the attention of the 
mother by his behavior, which is so markedly changed. During this 
period I have found that headaches and crying-spells are not uncommon 
precursors of the next stage, which may begin after two or three months. 

Stage of Development — Marshall Hall, 1 in his description of the 
hydrocephaloid diseases, alludes to the importance of vomiting as an early 
symptom. " The most frequent and formidable in appearance . . . 
is vomiting. Never, never allow vomiting in an infant to pass without 
paying the utmost attention, and making the strictest inquiry in refer- 
ence to the functions of the brain." Vomiting is generally the first and 
most important symptom, and convulsions are next in importance, but 
these two maybe associated or appear alone. Vomiting may be frequent, 
and is nearly always accompanied by an aggravation of the symptoms 
of the premonitory stage. Headache and increased temperature are pre- 
sent, and are very decided evidences of the gradual development of the 
trouble. When we arrive at this stage, which lasts two or three days, 
we may expect the appearance of the following symptoms : A marked 
rise of temperature, say from 101° to 105° F., with greatly increased 
pulse. The bowels are still constipated, ;uul there is but little appetite. 
The patient is delirious at night, and shrieks, cries, and tosses continu- 
ally. At about the sixth or seventh day, there are various local troubles, 

such as unequally dilated pupils, slight Btrabismus, but do actual loss of 

consciousness ;is yet. There IS a slight increase in the evening tempo- 

1 Lecture on the Nervous System and it- Diseases, L. and E. Philadelphia, 
1886, p. 92. 



54 DISEASES OF THE CEREBRAL MENINGES. 

rature, and the pulse is irregular and ranges from 110 to 120. The tenth 
day finds him much worse ; his excited condition being supplanted by one 
of stupidity. He does not recognize those in the room, and is utterly 
indifferent to the kind attentions of his mother or nurse. When the 
linger is drawn across the skin it leaves a vivid red mark, which has been 
considered one of the strong pathognomonic signs. The pulse is greatly 
accelerated, and perhaps reaches 170, while the temperature may be found 
to be 104° or 105°. His condition during the tenth and eleventh days 
is very little changed, though the apathy is if anything exaggerated. The 
belly is retracted, and his facies is highly characteristic, the patient having 
a worn and pinched look. The skin is dark and congested, and his eyes 
may be lixed and immobile, and there may be either strabismus or a 
rolling upwards of both eyeballs, so that a large part of the sclerotic is 
exposed. Subsultus tendinum and " picking at the bedclothes," with 
involuntary passage of feces and urine, are grave forerunners of a fatal ter- 
mination. The pupils are dilated, the pulse small, thready, and quick, 
and respiration is very slow. The temperature is still high, though the 
surface may be cold and clammy, and just before death the pulse quickens 
and becomes almost imperceptible. Slight rigidity now becomes apparent, 
the patient cannot swallow, stertor follows, and then death. Marshall 
Hall 1 tersely describes this last stage as follows : " The third stage is 
denoted by coma and its concomitant diminution of the sentient and volun- 
tary system, and eventually of the powers of the excito-motory system. 
There are blindness, deafness, deep stupor, absence of voluntary motion. 
At first the eyelids are constantly half closed, but still close completely on 
touching the eyelash. Afterwards this excito-motory phenomenon ceases. 
The n-pi ration becomes irregular, alternately suspended and sighing, and 
at Length stertorous. The sphincters lose their power, and the feces and 
urine are passed unconsciously." The appearance ©f the little patient 
just before death, is unmistakable. He lies with knit brow and flushed 
face, one side of which is drawn, while the eyes are fixed and glassy, and 
utterly devoid of expression. 

The duration of the disease rarely exceeds twenty-four days. It will 

be well to dwell more fully upon certain symptoms. Temperature There 

Beems to be at firsl an elevation of temperature, which lasts through the 

first lew days, say three or four, and after this time the temperature falls, 
until the Bixteenth or eighteenth day, when it may either go much lower, 
or be again increased. The variations are between the normal standard 
98.2°, and 105°. It however rarely reaches this high point. The sur- 
face temperature of the body is much diminished during the latter stages, 

but the head is always hot. Pulse Infrequent and irregular pulse is 

characteristic of the earlier stages of this disease, and during the last days 
there is increased frequency and more evenness. During the firsl two 
weeks this infrequency is to be observed, but after this i1 may steadily 

increase ten, twenty, or thirty beats more each day until at la>t it cannot 



Op. cit., p. 98 



ACUTE GRANULAR MENINGITIS. 



55 



be counted. This rule is not without its exception, and I have found 
intervals when both temperature and pulse would fall to the normal stand- 
ard, and continue so for some days, and afterwards rise. The pulse is 

Illustrative Chart of Temperature. 
Pulse and Respiration Variations in Acute Granular Meningitis, 



Days of 

Disuse. 


/ 


2 


3 


♦ 


s 


6 


7 


J 


7 


/£ 


n 


/£ 


/J 


/♦ 


/s 


/6 


n 


ft 




107° 
106° 
105° 
104° 
103° 
102° 
101° 
100= 
99° 
98° 


WE 


M E 


M E 


l-l E 


M E 


M E 


M E 


M E 


M E 


M E 


H E 


M E 


M E 


H E 


M E 


M - 


M E 


M E 


o 
co 






































to 








































































!/ 


5 


















A 


/ 






/| 












< 

Cfc 






l\ 








/ 






\/ 


l/ 


/ 


/ 


1 — 










5 






f 




/ 


,/ 


./ 


1/ 


J 




V 


V 


V 












D 




/ 


V 


V 




'1 


V 




V 




















ii 


/ 








r 




























- 


/ 




































— 


180° 
170° 
160° 
































,/"" 


■""'I 
































/■' 
















































150 
140 
130 
120 

110 

Too" 

90 
80 
70 
60 






































" 






































» 




















/ 


















Pd 




















/ 


















fc 






/ 


\ 












J 



















H 




J 


/ 


\ 








/ 


^ 


















io 




/ 




» 


^ 


^ 




/ 






















Cm 


/ 










X 


w 




































































































j5 


50 
45 

40 | 

35 

30 

25 

20 

15 












































































! 






































FL< 






































s 






































H 
-< 




























































































































> 


... 

i— — ~~~— ~v • 











A. Indicates sthenic character, 

15. Indicates irregularity . 



perhaps more rapid when the disease is being developed. 1 append a 

chart, which will enable the reader to Bee at a glance the condition of 



56 DISEASES OF THE CEREBRAL MENINGES. 

pulse, temperature, and respiration in a typical case. Various modifica- 
tions of the cutaneous circulation have been dwelt upon by Trousseau and 
various writers. There seems to be an extensive disturbance of the vaso- 
motor distribution of the skin, and when the surface is brushed or rubbed 
ever so lightly, or even when slight pressure has been made by the pillow, 
there will remain a bright red mark. This condition of the cutaneous cir- 
culation is not limited to the integument of the head, but may be present, 
especially towards the end of the disease, over the whole body. Trous- 
seau 1 has called attention to the " tache-cerebrale," which is the name 
given to the appearance presented when the finger is passed over the sur- 
face, and a red line remains. 

This author finds that when he made cross-markings upon the abdomen, 
in less than half a minute the portion of skin which he had touched was 
suffused with a very bright red tint, which disappeared slowly, the lines made 
hv the finger-nails remaining after the others had faded out. The regions 
where this redness is produced most easily are the anterior parts of the 
thighs, the abdomen, and face. Respiration — There are the usual fall and 
irregularity which accompany collapse of all kinds ; and sighing and 
diminished respiration are features of the later stages. Sensorial Dis- 
turbances Headache of a deep and throbbing character is very severe 

and continuous, lasting until coma supervenes. Various indications of the 
patient's sufferings are conveyed by his behavior. He presses his thumbs 
against his temples, or locking his finger on top of his head, holds his head 
in his hands, and gives vent to suppressed groans or shrieks, holding his 
breath sometimes as if fearing that the very effort of expiration might 
increase the pain. The cry of the patient is heart-rending, but I am not 
disposed to agree with Trousseau that it has any decided periodicity, 
though there may be intervals of silence. HypeTOsthesia of the scalp, 
photophobia, and tenderness of the muscles at different parts of the body 
are usual accompaniments. Bertalot 2 of Pfeddersheim, in an analysis of 
2 1 cases, has found photophobia to be more commonly a symptom of the 
later Btages, in which conclusion I am inclined to concur. The psychical 
Bymptoms are present in every case, though delirium is not so common 
among very young children, and when it does occur is followed by a slate of 
Bemi-conscioushess, and finally by coma. The patients will not speak, 
rebel againsl food and interference of any kind, and after a time it is 
very difficult to arouse them. One very interesting fact is that the 
coma is never sudden, hut is preceded in every Instance by either somno- 
lence or delirium of the mill tering variety. The coma sometimes becomes 

lese profound in character, and there may he a lucid interval before death. 
Motorial Disturbances. — The eyes are Dearly always affected; and the 
ocular trouble is either strabismus, ptosis, or a pupillary change. The 
former is an early Bymptom, and is probably <Jie first indication of para- 
lysis of any kind, and is seen most perfectly ^hen a patienl is awakened 



1 Lectures u|'«>n Clinical .Medicine, Am. edition, vol. i. p. S77 

■ Jahrbuch flir Kinderheilkunde, W. 9, H. ::. 



ACUTE GRANULAR MENINGITIS. 57 

or aroused. The pupils are sometimes unequally dilated, but when the 
coma supervenes dilatation is complete; pupillary changes are, however, 

by no means constant. 

Unilateral paralysis is not rare ; some of the facial muscles being alone 
affected, or there may be extensive hemiplegia, which is an advanced 
symptom. Spastic contractions are evidences of a condition of central 
irritability; and rigid flexion of the muscles of the thumb, or muscles of 
the sub-occipital region, are examples of this kind. The patient com- 
monly lies with his thumbs drawn into the palm of the hand and covered 
by the fingers, and it is sometimes difficult to open the hands. 

I have alluded to convulsions, and in addition may say, that they are 
more prominent in the first four days, and vary in severity if the coma be 
either very deep or there is a condition of semi-consciousness. In the 
latter case they may involve isolated groups of muscles. 

Ophthalmoscopic Signs Bouchet, 1 Galezowski, 2 and numerous ob- 
servers have called attention to the value of the ophthalmoscope as an 
instrument for diagnosis in tubercular meningitis. The latter has found 
two forms of neuritis as evidences of this disorder ; one a peri-neuritis, 
and the other an inflammation of the optic nerve itself. Whiteness about 
the papilla, deposits of granular matter in the choroid, and tortuosity of 
the retinal vessels, are appearances which have been described by others. 
Fr'ankel 3 and Steffen found tubercle in the choroid some weeks before the 
invasion of the disease; and Broadbent, 4 in examining the fundus, dis- 
covered that the optic disks were dusky red, and mottled by white spots ; 
and the retinal veins were enlarged, while the arteries were very small. 
Tubercular meningitis of the convexity presents no ophthalmoscopic signs. 

ACUTE GRANULAR MENINGITIS OF THE CONVEXITY. 

In the table I presented when speaking of the basal division of this dis- 
ease, I mentioned the prominent symptoms of this variety. When I add 
that delirium and other decided psychical symptoms are highly charac- 
teristic of inflammation of the vertical region, I have described the differ- 
ence between the two forms. This variety runs its course in a much 
shorter time, death generally resulting in from a week to ten days. 

When the malady (either basal or vertical) occurs in conjunction with 
certain tubercular affections of the lungs or peritoneum, there are local 
symptoms which precede those of the meningeal disorder, but the invasion 
of the disease is often very sudden. Constipation, followed bv a typhoid 
state and drowsiness, are the precursors of meningitis when antecedent 

1 Du Diagnostic des Maladies du Systeme nervcux par [' Ophthalmoscope. 
Paris, L866. 

2 Arch. Gen., 1867, vol. ii. p. 262. 

3 Virchow's Jahresbericht, 1869, p. 651. 

4 Trans, of London Pathological Society, vol, xxiii. p. 216. 



58 DISEASES OF THE CEREBRAL MENINGES. 

lung disease lias existed. Not only may children be subject to this dis- 
ease, but adults are as well ; and we sometimes find it as a sequence of 
various zymotic diseases, typhus or typhoid, remittent and other fevers, as 
well as pulmonary tuberculosis. A marked elevation of the evening tem- 
perature, incomplete hemiplegia, vomiting, or convulsions, are the promi- 
nent features of such a termination. Strabismus, unequal mydriasis, high 
pulse, and temperature, with some of the other symptoms which charac- 
terized the disease in the child, that have already been described, are 
generally present. 

It is sometimes so insidious in its approach and development as to puz- 
zle the observer. The phthisical patient may become listless, drowsy, or 
complain of headache. He often wanders and gives way to a mild form 
of delirium, which appears during the latter part of the day. This com- 
plication may occur during the early stages of the pulmonary affection. 

Causes The question of diathesis naturally arises before any other. 

and we are immediately puzzled, for on one side we find that Rokitansky, 
Robin, Empis, Clark, and others consider the disease not to be directly 
connected with the tuberculous diathesis, and they go so far as to question 
the identity of the granular deposit in the brain with tubercle; while 
aiiayed against them are Rilliet, Barthez, Grisolle, and a host of others 
who are equally positive that it is in every case an expression of tubercu- 
losis. Leaving the discussion, which is by no means settled, as the nature 
of the deposit needs much more investigation than it has received, we may 
assume that the affection is usually associated with a "scrofulous" cache- 
xia; that it appears among children who are badly nourished, and in whom 
the nervous diathesis is well developed. That exposure, insufficient food, 
and various exciting causes, such as dentition and over-study, produce it, 
no one will, I think, deny. In some instances — and these are by no 
means few — it is impossible to find any hereditary tuberculous history. 
A- to age, we may consider that the so-called primary tubercular menin- 
gitis rarely occurs after the fourteenth year, and it is probable that a great 
many of such cases are unattended by tubercle, but by a granular deposit 
of simple character; and primary tubercular meningitis in after life is, I 
think, a genuine tubercular disease. 

Watson 1 makes the statement that fifty children arc attacked within 
the first five months of life to everyone after that time. I have found 
it to be more common alter the first year, between the first dentition and 

the fifth year, though general pract it ioners who see more of these cases 
undoubtedly find them before that time. In large cities the mortality 

is undoubtedly greatest in the summer months, when diarrhoea! as well 
:i~ other diseases and high temperature are conducive to its development. 
In the year 1871, in the city of New York, 84 deaths from "tubercular 
meningitis" (the reported exciting cause behlg "teething") are recorded 
in the Health Board Reports, and the greatest Dumber were found be- 
tween tic Bixth and fourteenth years, a fad which seems to he Irre- 

1 Practice of Physic, p. 270. 



ACUTE GRANULAR MENINGITIS. 



59 



concilable with the statement that it is generally connected with the first 

dentition. 1 

The table presented below demonstrates that males are much more 
frequently affected than females, and of 1 »"»'.» deaths ' ( 1 were of males and 
7' s of females. Bertalot, already referred to, found that of hi- 24 cases 
fourteen were boys and ten were girls. Two cases occurred in tin- firsl 
year of life, seven in the second, five in the third, three in the fourth, 
three 1 in the twelfth, and one each in the fifth, ninth, tenth, and fourteenth 
years. The youngest patient was ten weeks old. Twenty-two «.iit of the 
twenty-four were attacked between November and the end of June. The 
children were all more or less delicate, they had frequently grown up 
under bad hygienic conditions, and were generally scrofulous or scrofulo- 
rachitic. In twelve there was a distinct hereditary predisposition to 
tuberculosis; two cases supervened upon chronic coxitis ; one upon trau- 
matic erysipelas ; two upon pertussis; one upon measles; and one upon 
the first signs of dentition. 

Morbid Anatomy and Pathology From the immense mass <>t 

confused testimony before ns (for the disease lias been described by nearly 
every writer, from the time of Hippocrates), it is extremely difficult to 
say whether the post-mortem appearances are always those of a tuberculous 
character, or whether the granular substance is non-tuberculous, or again 
whether in some cases there is tuberculous deposit and in others simple 
granular collections. Paisley, who. Watson says, was the first to clearly 
describe the affection without saying much about its tuberculous nature. 
has given us a very admirable collection of facts bearing upon its morbid 
anatomy. 

Gerhard. 2 one of the early medical writers of this country, says : " It 
was not known, previously to the researches of Dr. Rufz and myself, that 
the tuberculous character of the disease was anything but a mere compli- 
cation." Guersent, Dance. Hennis, Greene, and others shared in Ger- 
hard's opinion, that tubercular meningitis was a " strumous" disease. 

Rufz 3 collected 40 cases, and in every instance there was complicating 
pulmonary tuberculosis. 



1 An inspection of the table prepared by Dr. C. P. Russell, in the Report of the 
Board of Health of the City of New York for 1870, will enable the reader to 
perceive the preponderance of mortality before the second year ot life. 



\ ity. 


Color- 
ed. 


I'nder 

1 


1 








4 


s 


10 










U.S. 


For' n. 


•: 


3 


l--> 


- 


•->-, 


M. F. 


II P. 

9 2 


M. r. 
" 


M P. 

:?' 28 


Iff. P. 


M 


P. 
9 


If. P. 

TT 


M P. 

4 : 


M r M. F. 
7 .? 4 4 


Iff. 


P. 


_ T 


Iff. P. 



Also (i\e males of :>". one of 50, ami one of .'>:>; this cause ot' death w - 
per cent. <>f the combined cause. 
■ Dunglison's Prac. of Med., vol. ii. p. 243. 
3 Quoted by Marshall Hall, p. :>4. 



60 



DISEASES OF THE CEREBRAL MENINGES. 



Fenwick's 1 tables are valuable in displaying the distribution of tubercle 
in the affection. 

In one of these, sixteen cases of meningitis occurring in tubercular 
patients are detailed in which tubercle was found in the lungs and other 
organs, but not in the brain. 

In these cases, of which ten were males and six females, there was tu- 
berculous deposit in the lungs in every instance, and in some of them 
other organs were affected. Positively nothing like tubercle could be 
found in the brain, but this organ was either congested or anaemic. The 
membranes were " wet," and the ventricles contained fluid. Four cases 
were under ten years of age ; three between ten and twenty, and three 
between twenty and thirty ; four were in the fourth decade, and one in 
the fifth and sixth. In other cases brought forward by him of general 
tuberculosis, it was found that of fifty-four examined, nearly four-fifths of 
the number were below twenty-five years. All of these fifty-four had 
tuberculous deposits, both in the brain and other organs. 

The seat of the granular deposit seems to be chiefly the arachnoid and 
pia mater, though the dura mater has been found as well to be the site of 
granular accumulation. It is scattered mostly along the base of the brain 
and about the large arteries, where it may be found to consist of masses of 
little round pearly or yellowish bodies which may be almost as small as 
grains of coarse corn meal. The meningeal arteries are dotted over with 
these granules, and when the arachnoid is raised numerous underlying 
miliary granules are exposed. 




Tuli. -mil. mis Matter about the Vessels. (Cornil ami Itanvior.)— A. Tuberculous deposit. 
B. Wbito blood-corpuscles. C. Granular contents of vessel. 

The membranes arc all more or less congested and dotted with opaque 

Bpotfi Or patches. The cortex is hyperaemic and the ventricles distended 

l»\ fluid. Their ependyma is toughened and rough, and presents a granu- 
lar appearance which may he Likened to thai, of a piere of white shark's 

Bkin. 

Softening of various parts of the brain, the nerve trunks and optic 



st. George' a EIosp. Reports, \<>1. vii. p. .'5a 



ACUTE GRANULAR MENINGITIS. CI 

commissure are not uncommon evidences of the violence of the dia 
Patches of false membrane which contain in their meshes these granular 

bodies are scattered over the convexity and base, and render the removal 
of the brain or its membranes separately a somewhat difficult matter. Tic- 
lungs, or other organs, may also present indications of tuberculous matter. 

Rendu 1 affirms that whenever there is paralysis of permanent form there 
must be some arterial obliteration from fibrinous exudation and consequent 
softening, and he does not believe that scattered granulations or ventricu- 
lar effusion are alone sufficient for its causation. 

It is rarely possible to very closely localize limited deposit before death. 
but occasionally this may be done. 

A very interesting case is reported by Baymond which presented seve- 
ral suggestive points. One was that the motor centre of the right arm 
was the seat of granular lesion, and that there was paralysis of that mem- 
ber. This, then, is an exception to the rule to which I have just re- 
ferred. 

" The patient, a man twenty-two years of age, was admitted into the 
hospital in the early part of the month of January last, and then presented 
obvious symptoms of pulmonary tuberculosis, not, however, very pro- 
nounced. The affection, indeed, seemed so be progressing slowly. He 
was thin, pale, coughed a good deal, and was a little feverish. 

" On January 28 he began to complain of violent pain in the right hy- 
pochondrium, and two days later vomiting eame on. This recurred fre- 
quently, the ejected matter having a greenish color. At the same time 
he suffered from severe headache, which affected chiefly the left side of 
the head. Fever then showed itself, the temperature rising to 140° ; the 
pulmonary lesions developed more rapidly, and the general condition be- 
came much worse. On March 2-4 he complained of great pain in his 
right arm, which seemed to be very heavy ; at times he had great difficulty 
in moving it. On March 25 there were fresh pains in the arm. and motor 
paralysis was complete, sensibility being retained. In the evening, with 
a great effort, he succeeded in raising his arm to his head. The paralysis 
of the arm, up to the time of his death, presented the character of inter- 
mittence. There never existed any trace of paralysis in the right leg nor 
in the left arm or leg. Perhaps there was a slight degree of loss of power 
in the bucco-labial muscle of the right side, and a slight deviation of the 
tongue to the left, but these symptoms were a little doubtful. In the 
whole case, there was nothing else comparable with the paralysis o\' the 
arm, which was indisputable. The patient died on April 4. 

"At the necropsy, far advanced tubercular lesions were revealed in the 
right lung, and the membranes of the brain were found to be the seat of 
tubercular granulations. These were found in the pia mater over the 
right lobe, and there they were disseminated along the parietal branch of 
the Sylvian fissure. On the left side, in addition to the tubercular granu- 
lations, there existed some meningitis with purulent deposit-. The men- 
ingitis was, if it may be so said, circumscribed and localized on two con- 
volutions, the anterior and posterior marginal near the paracentral lobe, 

1 Review in Gaz. des llopitaux, Jan. 15, 1878. 



62 DISEASES OF THE CEREBRAL MENINGES. 

There the tubercular granulations were very numerous, and formed a sort 
of tumor. The pia mater, covered with pus, adhered closely to the sub- 
jacent cerebral tissue. In other parts, where there were granulations, 
there was no vestige of meningitis. No other cerebral lesions, foci of 
softening, or obliteration of capillaries, could be discovered. There was 
a small amount of fluid in the ventricles, but nothing to note in the spinal 
cord or nerves of the arm. 

" Such are the facts of this case, which may be summed up as follows : 
Motor paralysis of the right arm, somewhat intermittent in the sense that 
it was at times complete, and at other times less absolute ; and to explain 
this paralysis no other lesion than the tubercular meningitis in the region 
of the motor centre of the arm." 1 

Prognosis. — No inflammatory disease of the brain or its membranes 
is more serious or rapidly fatal than is this. The termination is in death in 
from two to three weeks, though very rarely recovery may take place be- 
fore the disease has gone beyond the period of invasion. The ophthal- 
moscope is our best friend at this time. If there be optic neuritis, and 
basilar meningitis is suspected, there is very little comfort to be derived 
from such an examination. If the child recover, it will be with impaired 
intellect, epilepsy, or some other serious life-long trouble. 

An anonymous writer in the Gazette Medicate upon the treatment of 
tubercular meningitis, says that, in a practice of thirty years, he has seen 
between eighty and ninety cases, and during that time there were but two 
recoveries. 2 Bierbaum 3 has reported three recoveries. 

Diagnosis This disease may be mistaken at different stages for 

several other acute conditions, viz.: — 

A. Typhoid fever — typhus fever. 

B. Scarlet fever or smallpox. 

C. Pleurisy or pneumonia. 

I). Eccentric irritation, such as that produced'by worms, etc. 

E. Other forms of meningitis. 

F. Exhaustion. 

A. Typhoid, in some of its forms, or typho-pneumonia, may resemble 
tubercular meningitis, either of the primary or secondary forms. This is 
especially the case when typhoid symptoms are added to those of phthisis. 
The irregular varieties of typhoid are attended by absence of diarrhoea, 
tympanites, and other abdominal symptoms. The eruption of typhoid may 
also resemble the tache cere'brale of this form of meningitis, but it is 
usually confined t<> the chest and abdomen, and is an early symptom. 
Typho-pneumonia may bear a (dose resemblance to secondary tubercular 
meningitis, and this is particularly the ease [f moist rales can be heard all 
Over the che8t, and there LB some dulness at the apex. Certain points are 

I. Mud. .11 Med. Record, July L5, is,7<;. Abstract from Le Progrej M6dical, 
April 22, 1876. 
* Gazette MSdicale, 1871, 412. 
1 Deutsche KJinik, is;:;. 184, 



ACUTE GRANULAR MENINGITIS. 

to be borne in mind, "however, that will put the diagnostician on his guard. 
Uncomplicated typhoid is a disease of longer duration, and the abdominal 
symptoms are usually marked. There is tenderness in the lefl iliac fossa, 
high evening temperature, nose-bleed, and usually slight head symptoms, 
which vary. The eruption fades away under pressure, instead of being 
produced by pressure or contact, as is the case in the meningeal difficulty. 
The prodromal symptoms of typhoid arc not nearly so marked as those of 
the other disease. 

Typhus fever may sometimes make the diagnosis exceedingly difficult ; 
for, as Ave know, its duration is about that of the tubercular trouble, and 
head symptoms are its marked feature. The general absence of pulmo- 
nary symptoms, the appearance of the dark rash, and the antecedents of 
the patient offer us guides. 

B. Scarlet fever, which sometimes begins with vomiting and early head 
symptoms, puzzles the observer. The throat trouble, the early appear- 
ance of the eruption, the peculiar " strawberry tongue" which, as far as I 
am aware, is found in but two diseases, diphtheria, and scarlet fever, and 
the high and continued elevation of temperature during the eruption, are 
sufficient to put the medical man upon the alert. 

Smallpox, without the eruption, may sometimes mislead us. The pro- 
dromal symptoms, pain in the back, vomiting, and headache are different 
from the same symptoms in tubercular meningitis. They are more severe, 
and may immediately usher in coma. Bleeding from the nose and mouth 
I have witnessed in three patients. This form of smallpox is quite ran 1 . 
In the course of six years, during which I have been connected with the 
Health Department of the City of New York, I have seen over one 
thousand cases of the disease, and I do not remember having encoun- 
tered but ten or twelve cases of this terrible form of variola. These cases 
were all adults. If pronounced smallpox should suggest the other affec- 
tion, it will be found that in two or three days any blush eruption (which 
could hardly be mistaken for the maculae of tubercular meningitis, which 
is a late symptom) will develop so that the characteristic vesicles may be 
seen. In both scarlet fever and smallpox the history of exposure often 
supplies the link. 

C. Pneumonia and pleurisy can only be mistaken when we neglect to 
take into account the chill, pain in the side, and physical signs. The 
latter disease may sometimes be supposed to exist ; for Gee has heard the 
friction sound of pleurisy in tubercular meningitis. 

D. Reflex irritation from ascarides may produce many of the early 
symptoms which also indicate tubercular meningitis, and even convulsions 
may appear; but. unlike the tubercular disease, there is no further pro- 
gress. The use of an anthelmintic will clear up the diagnosis, if we have 

reason to suspect these parasites. 

E. From simple meningitis we may distinguish the disease chiefly by 
the late appearance of the delirium. The patient lapses into unconscious- 
ness in the former disease in tWO or three days, while in tubercular meiiin- 



64 DISEASES OF THE CEREBRAL MENINGES. 

gitis the acute mental disturbance is not so immediate. Acute meningitis 
runs its course usually in a week. 

Various intracranial diseases may resemble at different times the disease 
under consideration ; but as I propose to treat of these hereafter, it will be 
well to omit them here. 

F. Exhaustion The excitement that has been lately aroused in Eng- 
land by the Penge case gives this part of the subject decided importance. 
It will be remembered that one Louis Staunton, with two accomplices, one 
of whom was his brother, and the other a woman with whom he was living 
upon terms of criminal intimacy, starved to death his wife, and that they all 
narrowly escaped capital punishment or transportation. The coroner's jury 
decided that the real cause of her death was starvation, while several dis- 
tinguished medical men contended that she had died from tubercular menin- 
gitis, but did not deny that she had been neglected. The disputed points 
seemed to be, the rapid emaciation and great anaemia of the tissues, as well 
as disappearance of subcutaneous fat. Her symptoms before death were 
drowsiness, passing into coma, stertor, rigidity of one arm, and inequality 
of pupils. These symptoms appeared but shortly before death, and were 
supposed by Dr. Greenfield, 1 who made a most sensible and convincing 
communication to the Lancet, not to account for starvation alone, but to be 
probably due to tubercular meningitis. 

Opposed to him are several observers (among them Virchow, who re- 
viewed the English testimony), who held that the great emaciation, loss 
of weight of the internal organs, emptiness of the cavities of the heart, and 
certain forms of congestion were clearly indicative of starvation. Green- 
field proves, I think, that none of these appearances were sufficient in 
themselves for us to say definitely that they were due to starvation ; that 
they may often be a result of exhausting disease; that the congestion wit- 
aessed was an ordinary post-mortem appearance; and finally that tubercle 
existed in the lungs and brain; while in the latter there were found pri- 
mary indications of softening as well as adhesion of the meninges. 

Gee calls attention to forms of wasting disease with profound emaciation 
which may closely simulate tubercular meningitis, but are connected with 
digestive derangements and malnutrition; and Sir Wm. Gull, in one of 
the English hospital reports, brought forward several cases of hysterical 
anorexia; and in the profound form of cerebral anaemia there can be symp- 
toms which may resemble some of those expressed in tubercular meningitis 

so greatly, B£ t<> possibly lead to an error in diagnosis. 

Treatment More can be done for the patient in the early stages 

than at any other time. Cod-liver oil, phosphorus (F. 37), a nitrogenous 

diet, and preparations of iodine are all of great service. The syrup of the 
iodide of iron (F. 42) 18 an excellent reined\ in the earliest stage, if we 

recognize the significance of the somewhat jjrregular group of symptoms. 

The iodide of potassium has been by many used during later stages. 

1 London Lancet, Oct. 6, i s 7 7 . 



CHRONIC CEREBRAL MENINGITIS. 05 

Fleming 1 reports a cure in the case of a girl two and a half years oM by 
large doses of the iodide, and the experience of others is also encouraging. 

Cold to the head and the bromides in the later stages are of greater benefit 
than any other remedies. Ergot has been successfully used by Gibney in 
one case of so-called tubercular meningitis. It should be administered in 
full doses often repeated. Gee recommends closure of the eyelids by ad- 
hesive plaster, should there be any ulceration of the cornea. Blistering, 
bleeding, and violent treatment of any kind are to be strongly condemned ; 
quiet and darkness should be insisted upon as early as possible, and over- 
solicitous friends should be excluded from the sick-room. Food of a liquid 
form may be given by enemata, or by the mouth, using a syringe, and 
being careful in introducing its point between the teeth. 



CHRONIC CEREBRAL MENINGITIS. 

This very rare disease, which may be either the result of acute menin- 
gitis, or develop idiopathically, or after head injury, is of slow appearance 
and progress, and resembles several organic diseases of the brain proper, 
among them softening, general paralysis, and brain tumors. 

Symptoms One of the early symptoms, especially of the vertical 

variety, is headache, which varies in severity. It is of a dull character, 
and is seated in the top of the head, and is increased by any effort which 
augments the cerebral blood pressure. In certain cases there is los 
memory, and other mental symptoms, which resemble closely those of 
general paralysis of the insane ; and this mental impairment may terminate 
in dementia. The vertical form is generally complicated with encepha- 
litis and muscular paralysis, as well as spasms and twitchings of either a 
limited group of muscles, or the arm and leg of one side. Tremor and 
sometimes convulsions occur after a short period, while after the involve- 
ment of the cortical substance we may have marked motorial symptoms, 
such as paralysis with contractures, and paralysis of the bladder or sphinc- 
ters, both of the bladder and rectum, so that the patient passes his urine 
and feces in an involuntary manner. The disease is generally progressive, 
and there is an increase in the number of convulsions. The mental decay 
advances rapidly, and the patient finally dies, at the end of a few months, 
in a comatose state. The basilar form of disease is much more interesting 
than that of which I have just spoken, the cranial nerve- being more or 
less involved ; and symptoms of cranial paralysis of a progressive character 
form a distinguishing feature of the disease. Thus, in thirteen cases col- 
lected by Dr. Cross, 8 of this city, the third nerve was paralyzed generally 

on the left side in nine instances, and in one case the third pair on both 
sides was affected. In nine of these cases BtrabismUB was noted: in five 

of which it was external and existed on the left side. The pupil- were 

1 British Med. Journal, L871, p. L43. 

8 Psychological and Medico-Legal Journal, New Series, vol. ii. p. 220. 
5 



66 DISEASES OF THE CEREBRAL MENINGES. 

dilated in eight instances, and contracted once. Obscureness of vision 
was observed to be prominent in four cases, while ptosis existed in five, 
occurring once on both sides. Double vision was present in many cases. 
Blindness occurred once in the left eye, which was the result of suppura- 
tive choroiditis. In another instance there was loss of sight in both eyes. 
I may select four of Dr. Cross's cases, which represent very fully the 
course of the disease : — 

Case I. — A young man came to the clinic who was affected with 
external strabismus, ptosis, and dilatation of the pupil of the left 
eye. lie had a most intensely agonizing pain in the head, vertigo, 
frequent attacks of vomiting, and paresis, if not paralysis, of the arm and 
leg on the same side. lie was treated with mercury and large doses of 
the iodide of potassium. In a short time the pain in his head disappeared, 
and after the lapse of a few weeks the paralysis was cured. Two or three 
months subsequently he reappeared, with a corresponding set of symptoms 
in the right eye, and the right half of the body, and with pain in his 
head as severe as during the previous attack. He was again treated with 
mercury and the iodide of potassium, Avhen his symptoms again disap- 
peared, and have not since returned. In this case there was some slight 
suspicion of syphilis. 

C'a>k II — A man, twenty-eight years of age, came under my charge 
some two years ago. At that time he was suffering from pain in the 
head, vertigo, dilatation of the pupil, external strabismus, double vision, 
numbness, and slight paralysis of the opposite side of the body. As far 
as I was able to discern, the ocular paralysis was confined solely to the 
left internal rectus muscle. Until within a few months prior to his com- 
ing under my observation, he had apparently enjoyed excellent health, 
witli the exception of a severe headache, from which he had suffered quite 
acutely. He stated that the disease with which he was afflicted had come 
on slowly, and gradually increased in degree. He acknowledged that he 
had had a hard chancre several years previously. 

Under the influence of large doses of the iodide of potassium, the symp- 
toms rapidly disappeared, and he has since had no return of the paralysis, 
ah hough lie afterwards experienced severe headache, which disappeared 
under treatment. I examined his retina', but found no disease. 

Case III. — Shortly after this I was consulted in regard to the case of 
a gentleman, thirty-five years old, who was suffering apparently from 
Bymptoms similar to those observed in the preceding case, with the excep- 
tion of the paresis of the extremities. He had well-marked head-symp- 
toms and numbness, which was Limited to one side of the body, but the 
paralysis was confined exclusively to the ocular muscles. His eves had 
been carefully examined by an eminent ophthalmic surgeon, who had 
informed him thai they were healthy, and that his trouble was probably 
cerebral. II«' was a very robusl man, and had apparently suffered from 
no Bevere disease until the beginning of his present trouble. On question- 
ing him closely, he stated that he had had syphilis twelve years ago, for 
which In- had been carefully treated, and consequently considered himself 
cured. When I first s;iw him, the double vision had existed several 
months, and during that time had been almost constantly present. I did 
not treat this patient, ami consequently do not know the result. 

Case IV. — A married gentleman, forty-one years of age, came under 

my .an- in L878. He u;i- descended from a family saturated with rheu- 



CHRONIC CEREBRAL MENINGITIS. C7 

matism and gout, and five of whom had died of paralysis. At this time 
he was suffering from myalgia, which I found to be located in tin* muscles 

of* the chest and back. This condition lasted about three months, and 
then disappeared under treatment. He stated that prior to this time bis 
health had been good. He had been temperate in his habit-, and had 
never had acute articular rheumatism, gout, nor syphilis. Jn July. 1873, 
he first observed that the pupil of the right eye was much contracted. 
This was followed by headache, vertigo, and obscureness of vision. In 
December he came to my office and informed me that his ocular troubles 
had increased. At that time his condition was as follows: He had a dull, 
heavy pain behind the ears, which seemed to extend along the base of 
the brain, and was at times throbbing in character. There was vertigo 
and indistinctness of vision, which he described as a blurring of objects; 
his right pupil was extremely contracted, and did not respond to the 
stimulus of light. Far and near objects were very indistinct, and appeared 
to be one above the other. When he looked at the pavement it appeared 
to be raised above its natural position. There were double vision and 
strabismus. 

He kept his head constantly turned to the right and downwards, in 
order to bring the axes of his eyes parallel. All his organs were healthy, 
with the exception of his brain. There was apparently partial paralysis 
of the right internal rectus and right inferior oblique muscles. This gen- 
tleman was, by my advice, carefully examined by two eminent ophthalmic 
surgeons of this city, both of whom were of the opinion that there was no 
disease of the eyes. An important point in this connection is the fact 
that this patient had been in the habit, of using a magnifying glass with 
th<' affected eye to examine the delicate parts of machinery, in order to 
see that they were properly constructed; and this operation was con- 
ducted in a dark room, lasting several hours daily. I carefully examined 
this patient's spinal cord (as I always do in all these cases), but 
found no indications whatever of spinal disease. I ordered him to take 
the iodide of potassium, in fifteen-grain doses, three times a day, well 
diluted in water, and to rapidly increase the amount; but the first dose 
caused him such intense nausea and vomiting that he could not be induced 
to take it subsequently. He consequently ceased taking any medicine, 
and for some time he continued to grow worse, all his symptoms increasing 
in -<\erity. He was obliged to give up his business, and has since passed 
most of his time in out-door exercise. 

The pupil of the right eye remained permanently contracted for several 
months. A short time since I met him, and he told me that he was about 
to resume his business, he had so nearly recovered. His pupil was still 
contracted, but not to the same degree that it was when he firsl came 
under my care a year ago. lie now holds his head straight; there is no 
apparent strabismus, although his wife informs me that lie occasionally 
Bees double. His headache and vertigo have disappeared. The only 
medicines that he lias taken during this period have been tonics and out- 
door exercise. I made particular inquiry in this case, in order to discover, 
if possible, a constitutional cause, but I was fully satistied that none 
existed. 

Convulsions of a severe character are an alarming feature of the dis- 
ease when the base of the brain i> affected. Both of these form- of 



68 DISEASES OF THE CEREBRAL MENINGES. 

meningitis may be connected with cerebral growths and syphilitic and 
tuberculous deposits. 

Causes Males seem to be oftener affected than females, and the 

disease is ordinarily one of adult life. It is connected oftentimes with the 
tuberculous diathesis, and is not rarely dependent upon constitutional 
syphilis ; it may be seemingly idiopathic, or result from head injury, ex- 
posure to the sun, intemperance, the acute zymotic fevers, and the other 
causes of meningitis. 

Morbid Anatomy and Pathology The cerebral meninges have 

been found to be thickened, adherent to each other, or to the inner surface 
of the cranial bones, with effusions beneath, which have undergone partial 
organization ; sometimes gummy exudation of syphilitic origin will be 
found scattered over the surface of the brain, or calcareous plates of per- 
haps an inch in diameter will be found in the dura mater, such as I have 
already spoken of in chronic pachymeningitis. If the disease has involved 
the cortical substance of the brain, we may discover patches of softening 
of variable extent and depth, and perhaps superficial abscesses. At the 
base of the brain the meningitis is not generally so diffuse, but occurs in 
circumscribed spots, the cranial nerve trunks being generally softened and 
bound down by bands of new tissue. 

Diagnosis The form of meningitis of the convexity presents so 

many symptoms that are common to other brain diseases, that the matter 
of diagnosis is often very difficult, and it is impossible at times to deter- 
mine the nature of the patient's disease until after death. Meningitis of 
the base, however, is much more easily diagnosed. There are nearly 
always ophthalmoscopic appearances, which is not the case in the other 
form of disease, and some one, or all of the cranial nerves are paralyzed. 
The symptoms of tumor may counterfeit those of chronic basilar menin- 
gitis, but perhaps are more severe. If the disease be'of a syphilitic char- 
acter, the question of diagnosis is a puzzling one; for in some respects 
a condition which favors the formation of syphilitic tumor and chronic 
meningitis is the same, and occasionally these two diseases are found to 
coexist. 

Prognosis Should the disease be syphilitic, the prognosis is nearly 

always favorable, but, if it be the result of injury, recovery is less likely 
lo take place; should it follow the acute exanthematous levers, there is very 

little hope. 

Treatment Our main reliance is in the free use of large doses of 

iodide of potassium, or in the employment of mercurials. Active counter- 
irritation and the use <»t' blisters and cauterization may afford a great deal 

of relief. A saturated Bolutiol] of the iodide of potassium may be ordered, 
and the |»:ilicnl should be directed to begin with a dose of ten drops three 

times ;i day, and gradually increase one dropSrith each dose until he takes 

a hundred drops or more during (he twenty-Unir UOUTS. 



CEREBRAL HYPEREMIA. 69 



CHAPTEE II. 

DISEASES OF THE CEREBRUM ,\XD CEREBELLUM. 

CEREBRAL HYPEREMIA. 

Synonyms Cerebral congestion. Hyperemie cerebrale (Fr.). Hy- 

peramie des Gehirns (Ger.). 

Definition A condition characterized by an abnormal increase in 

the amount of blood contained in the cerebral vessels, and expressed by 
symptoms which indicate pressure, and irritation of the cerebral nerve- 
cells. Before entering into the discussion of this affection, I desire to 
state that in very few cases do I consider cerebral hyperemia to be a 
distinct cerebral disease, but rather one form of expression of some gene- 
ral condition. The apoplectiform variety described by Hammond and 
Trousseau is, in my opinion, generally a slight cerebral hemorrhage ; but I 
shall speak of it under this heading, for the reason that it is so commonly 
a result of acute congestion, while the striking feature of " cerebral hem- 
orrhage" ordinarily is the degenerated arterial state. 

Two forms of cerebral hyperemia have been recognized by the majority 
of medical writers, one of them which is active and connected with forci- 
ble arterial fluxion, and the other passive, and the result of some impedi- 
ment to the venous return. I prefer to adopt the terms sthenic and asthenic, 
as these expressions denote pathological conditions much more appropri- 
ately than do those in common use. Either may exist in a modified de- 
gree as physiological states, and it is often difficult to make the distinction 
between a normal process and a diseased condition ; but when the cerebral 
fulness is constant or increased to a serious extent, we may safely judge 
the condition to be pathological. The division of the disease expressed 
by the terms I have just mentioned, though adopted by most of the au- 
thorities on nervous diseases, is for some reasons unnecessary. 

Both varieties may lead to accidents symptomatized by attacks of coma, 
accessions of convulsion, a low grade of paralysis, mental excitement, and 
other serious results. These differ only in their manner of appearance. 
In one, they are early and sthenic expressions, and are produced by rapidly 
exerted and violent force; and in the other their advent is more slow, as 
ihey appear to be produced by a sluggish force or tardy impairment of 

Cell function, though sudden accident- which embarrass the venous return 

may make their appearance as immediately as those of the first variety. 

Stupor is more decidedly characteristic of the passive or asthenic variety, 

than that in which rapid dynamic arterial action takes place. In this, the 
second variety, there seems to he a dilatation of the BmaU vessels, a 



70 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

crowding out the perivascular fluid, and consequent pressure of the per- 
manently distended vessels upon the hyaline membrane next to the cells, 
thus preventing the removal of their effete material and consequently im- 
pairing their normal action. 

Symptoms The symptoms of this condition, as I have stated, may 

vary from evidences of what seems to be but healthy physiological function 
to those which are unmistakably grave pathological conditions; from sim- 
ple throbbing of the temporal vessels and flushing of the face, to coma, 
convulsions, or mania. 

Generally the symptoms are not serious, and out of the many cases I 
have seen (and, by the way, a large number of these mild cases are met 
with in private practice) they are of a type which may be recognized 
at once. The patient calls attention to the following troubles : A sense of 
head-fulness with throbbing of the temporal arteries. He may inform us 
that his " head seems to be of unnatural size and great weight ; that he 
feels as if the skin covering the head is much too tight." He complains 
of tinnitus aurium, and is troubled by subjective sounds which he 
compares to the buzzing of bees, the ringing of bells, and the rushing of 
waters. 

There seems to be an extraordinary acuteness of all the senses. He 
may complain of miisca volitantes, and inform us that there are bright 
speck- or motes which flit across the field of vision. He may say that 
bright light is painful, and complain of his inability to read fine print, be- 
cause the Letters seem to dance upon the page, and the words appear hazy 
and blurred. Diplopia and other visual troubles may annoy him. Sharp 
noises, harsh voices, and monotonous sounds seem to produce distress and 
discomfort. He may have hallucinations, but is generally able to appre- 
ciate their unsubstantial character. He arises in the morning unrefreshed 
and uncomfortable, complaining of muscular weariness, but feels better 
towards the middle of the day. After his dinner, particularly if it lias 
been a hearty one, the cerebral condition is aggravated. At night he 
finds it impossible to sleep, and he tosses to and fro, bis bead being hot 
and his extremities cold. The mind of the patient is preternaturally 
active, and his brain seems filled with excited fancies, and troubled 
thoughts — and at last he sleeps. This sleep, however, is not sound ; 
dreams of all kinds, or nightmare, keep him in a state of wretched semi- 
consciousness till the morning comes to find him utterly used up. 'With 
the patient, mental exertion is irksome, and study or concentration is 
disagreeable or impossible. There is headache or impaired memory, 
thickness of speech, and various difficulties of articulation. lb' may 
substitute one word for another, even though it be one in common use 
and exceedingly familiar. 

The emotions are generally disturbed and "altered. Irritability, nervous 
excitement, and morbid exhilaration of spirits may make his conduct. 
Btrange and unnatural to those about him ; while slight things seem to dis- 
turb and harass him. The attentions of friend.-, though they may be of 
the mo-i considerate nature, are met with explosions of temper, and the 



CEREBRAL HYPEREMIA. 71 

patient avoids them and prefers solitude. Sometimes lie takes violent 
exereise until completely exhausted, when wearied Nature asserts herself 
and sleep brings temporary relief. 

During the progress of the disease, cutaneous numbness or twitching of 
some of the muscles, or even paralysis, gives the condition a serious char- 
acter. The appearance of the patient is decidedly Btriking, and not to be 
mistaken. The face is red, the cheeks puffed and swollen, the eyes promi- 
nent, watery, and injected, and the conjunctiva' quite red, lie is anxious 
and excited, or, on the other hand, stupid. The sleepy expression is one 
of the most valuable objective symptoms. Occasionally, in the course of 
the disease, there is bleeding from the nose, which may temporarily re- 
lieve the patient. The hands and feet are usually blue and cold, and so 
remain. After a variable period, during which the patient has presented 
a number of these symptoms, he may suddenly, after a hearty meal, or 
violent exertion or some other exciting cause, suffer an incomplete loss oi 
consciousness, 1 which is generally of short duration, and from which he 
can be aroused in a few minutes. When spoken to he seems bewildered 
and confused, and takes but little notice of what is going on about him. 
There seems to be incomplete loss of muscular power, more confined to 
one side than to the other, and he is able when less dazed to make simple 
voluntary movements. He seems to be annoyed by any bright light that 
may be let into the room. His pupils are contracted usually, and respira- 
tion is labored, while circulation is uneven, there being an irregular pulse. 
At first the heart's action seems to stop altogether, but subsequently it be- 
comes quite energetic, and the pulse is bounding and full. If the attack 
be due to passive congestion, there may be a dilatation of the pupils, and 
the bloating and puffing of the face and fulness of the lips will be much 
more noticeable than when it is the result of the sthenic variety. During 
its continuance there is neither rigidity of the muscles nor stertorous 
breathing. The recovery is generally rapid, and after the apoplectic form 
of attack there may be some epistaxis and slight mental excitement. Oc- 
casionally convulsions occur as an evidence of cerebral hyperemia, and 
they are generally of an interesting nature, from the fact that they may 
closely simulate epilepsy, and have been confounded with that disease by 
certain writers, among them Trousseau. These attacks are preceded, in 
mosl cases, by prodromata highly suggestive of cerebral congestion, and 
they usually need some exciting cause for their production, when the 
patient, after becoming dusky, lapses into an unconscious condition, and 
after ineffectual attempts at self-control falls to the ground and is agitated 
by an epileptiform convulsion. Instead, however, of sinking into a deep 
sleep almost immediately afterward, as is the case in true epilepsy, he is 

wild and excited, somet imes maniacal, and finally sleeps from Bheer ex- 
haustion. 

Trousseau has stated thai these attack- are connected with tongue-biting, 

but this seems improbable, and he evidently confuses this condition with 
veritable epilepsy. 

1 These symptoms arc, without doubt, due to small hemorrhages. 



12 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

A form, which certain writers have called maniacal, may and does 
often occur without any of the characteristic symptoms of increased cere- 
bral blood pressure that I have described. It is the form Milner Fother- 
gill has so admirably described, 1 and characterizes usually the pathological 
condition, in which the nervous tissues attract an abnormal amount of 
blood to themselves. This variety is not necessarily connected with vas- 
cular excitement, suffusion of the face, etc. It results commonly from 
protracted intellectual labor and direct excitement, and the patients may 
be pale and bright-eyed, and active in all their movements. They are 
" high-strung," restless, and remarkably irritable, and at the same time 
are loquacious and voluble. Their thoughts and fancies seem crowded 
together, and are evidently originated much more rapidly than they can 
be expressed. " Sometimes their ideas seem to settle themselves around 
some prominent leading thought, the centre-piece of the rotatory chaos, 
while at other times there is mental excitement, with great volubility, on 
no subject in particular." The condition is one of exaltation, and there is 
a restlessness which is characteristic. 

There is rarely any forcible heart action, the pulse being normal, or, if 
changed at all, is simply small and irritable. This condition does not 
seem to be confined to any particular age, though in old people cerebral 
congestion is disposed to take this character. The mental features may 
be those of ordinary acute mania, and all the phases of psychical disturb- 
ance may be expressed at some time or other. Suicidal tendencies are 
sometimes present. A case of this kind is reported, where the indi- 
vidual, during an attack of congestive mania, cut his throat. The loss of 
blood relieved the cerebral fulness, and his reason returned, but too late 
to avert the consequences of the act. This condition is one of rapid pro- 
duction, and under prompt treatment may disappear. Embarrassment of 
speech may vary from simple awkwardness of articulation to decided 
aphasia. 9 The diinculty is rarely a serious or lasting one, and is relieved 
by appropriate treatment. 

Hammond 3 calls attention to a form of aphasia which attends passive 
cerebral hyperemia, but I consider this an unnecessary refinement of 
division. 

A.S I have before remarked, the second variety is more apt to be asso- 
ciated with deep stupor, and recovery is less certain and rapid. 

There may, indeed, he a form in which profound stupor, stertor, and 
full hard pulse are present, and which is almost always fatal. This follows 
profound narcosis by alcohol <>r opium, and the death of the individual is 
preceded by in\ oluntary discharge of feces and urine, and there is complete 
l<>-- '»i' \ oluntary muscular power. 

Before Concluding the description of the condition, it niav be well to call 
attention to ;i, form which is chiefly Confined to early 



1 Wesl Riding Reports, art. Cerebral Hyperemia, vol. \. p. 171. 

2 This grave form is probably due to some Lesion. 

■ Disease! of Nervous System, X. V. L877, p. i'-'. 



CEREBRAL HYPEREMIA. 73 

the course of other diseases, or it may exist uncomplicated. In many re- 
Bpects it resembles meningitis. It is characterized by elevation of tempe- 
rature and other febrile symptoms, among them vomiting, flushed face, 
headache, broken sleep, twitching of the limbs, constipation, and wandering 

delirium. Convulsions occasionally occur, .and the attack ends in deep sleep. 
Recovery is the rule, although the young brain is so delicate and the vio- 
lence of congestive diseases so excessive, that a passive condition may take 
the place of, and remain after the acute condition, and death may ulti- 
mately follow. Epilepsy not rarely originates in this way. 

Causes Calmeil 1 and others consider that men are far more subject 

to cerebral hyperemia than women, and I think clinical experience fully 
supports their views. Some occupations and vices of men are peculiarly 
apt to lead to disordered states of the circulation, while women, as it will 
be seen, are not affected nearly so often as the other sex, and generally 
suffer only at the menstrual periods or when there is a retarded flux. It 
is not confined to any age, but is commonly a condition of middle life, 
though special causes may influence its origin at other period-. 

As to the etiological bearing of climate and temperature, there has been 
much discussion. As far back as the time of Hippocrates 2 we have been 
told that it is a condition produced or aggravated by low temperature, in 
which opinion he is sustained by Aretams. 3 Cheyne and others consider 
that extreme heat favors this morbid state, and Hammond, Andral, and 
others contend that the greater number of cases occur in cold weather. 

As far as my own experience is concerned, I have found, that either 
extreme, heat or cold, may develop the disease, but the greatest number of 
my cases have arisen from exposure to the direct rays of the sun, or have 
been among men whose avocation led them to pass their time in hot places. 
Bakers, sugar-refiners, furnace-men, glass-blowers, etc. etc. are often 
affected, and it is hard to say whether these people, or those who overuse 
their brains, form the largest number. I give below a table which details 
the occupation of 1G0 of these patients. 



One Hundred and 


Sixty 


Cases of 


Cerebral Hyper cum ia- 


—Occupation. 


Bartenders 




. 18 


Lawyers 


. 


. 16 


Bakers 


. 


. 15 


Musicians 




2 


Blacksmiths 




. 19 


Merchants 




. 15 


Carpenters 




3 


Painters 




2 


( larpet-cleaners 




1 


Physicians 




G 


Foundrymen . 




. 6 


Printers 




•) 


Harness-makers 




•_> 


Reporters 




4 


Jewellers 




2 


Tail. >!•< 




1 


Seamstresses . 




5 


Teachers 




. i ;; 


Laundresses 




:; 


Miscellaneous . 




. 17 


Laborers 




8 






ice 



1 Maladies inflammatoire du Cerveau. 

■ Aphor., Lect. iii. i <;. 23. 

8 Aretaeus de Sieni et Cans, morbd. d. lih, L, c. 



74 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

By this table it will be seen that 04 were individuals whose pursuits 
subjected them to exposure to heat, and 54 were among persons who were 
hard students, worried business men, and the like. 

Immediately after the heated term of 1872 I saw many patients whose 
cerebral condition was produced by the great heat; but the disease 
may be due in many instances to exposure and cold, or is at least greatly 
aggravated by low temperature. Perhaps a reason for this may be that 
in cold weather the cutaneous circulation is not so active as during the 
warmer season, when the sudorific apparatus requires a free capillary 
circulation, and for this reason there is a determination of blood to the 
surface. In cases of sunstroke, as we know, the skin is generally parched 
and dry. 

As to predisposing causes we may enumerate them as follows: The 
organization of the individual, the existence of other disease, his habits, 
etc. Two classes of individuals may be the subjects of cerebral hypersemia 
— those of the thick-set plethoric habit, which Reynolds calls the "lax- 
fibred constitution," and those who are spare, well knit, and of nervous 
temperament. These latter individuals have generally hard, rigid arteries, 
arc past middle age, and are usually brain-workers. 

In those individuals who possess a well-developed arterial system, but 
such configuration of the neck and head as to prevent venous return, there 
is a tendency to cerebral fulness. There are several morbid conditions 
which markedly influence the development of this state — malaria, renal 
and cardiac diseases, and syphilis being among the number. In patients 
with enlarged and diseased kidneys which are unable to excrete the effete 
nitrogenous waste from the blood, it remains in the circulation, increasing 
blood pressure, and necessitating excessive activity and rapidity of heart 
action. Hypertrophy of that organ is a result, and the avails of the right 
vent rich; become greatly enlarged ; and having much' greater force than it 
possesses in its normal condition, it forces the blood with great energy into 
the cerebral vessels, and as a result there is produced the morbid condition 
of which we have spoken. Pulmonary disease, attended by diminished 
aerating space, sometimes has the same influence. Gout may be at the 
origin of cerebral byperaemia . ; and, as I have said, malaria x^vy often plays 
a very important part in the etiology. 

Syphilis I have found to have much to do with cerebral hypersemia. In 

this disease this condition of the cerebral vessels is not uncommon during 

the secondary and tertiary stages, bul more often during the latter. Men- 
tal perturbation and hysteria seem to be connected with these forms. 

An excessive indulgence in alcohol, immoderate eating and drinking, 
or the abuse of tobacco; continued venery, and disregard of the ordinary 
calls of nature, are all predisposing, and some of them exciting, causes. 

Protracted Or Unnatural intellectual labor, emotional disturbance, mental 

strain, and intense excitement of various kiads, are additional causes of 
gr< :it importance. 

[ntellectual labor al night, particularly when there is a gas-light above 
the head of the patient, or prolonged business worry, not rarely favors 



CEREBRAL HYPEREMIA. 75 

the determination of blood to the bruin. Night editors, students, and 
workers by artificial light are subject to this condition, and eye-strain 
from these occupations is a powerful factor in the causation. 

Myopia and various errors of refraction and accommodation are some- 
times at the origin of severe headaches of the congestive variety. Pro- 
longed grief, especially when the patient neglects his bodily comfort, 
and passes long days in mourning, eating little, and gaining no sleep, is 
also a cause. The acute condition is not rare among nurses who have sat 
up at night; and they, as well as other night-workers, are very apt to 
combat the disposition to sleep which is healthy, by stimulants, coffee, or 
other agents, and after a short period a disagreeable state of congestion 
follows. 

As distinct exciting causes I may mention alcoholic abuse — pressure 
made upon the veins of the neck by tight collars or other articles of dress 
— sudden exertion of any kind, such as straining at stool, or during child- 
birth, and lifting heavy weights. In one of my patients, the simple act 
of bending over to button his shoe was sufficient to produce an alarming 
condition of the cerebral circulation. In some persons the condition is 
aggravated, or attacks of the severer kind are precipitated by a visit to the 
theatre or some crowded place of amusement, where ventilation is bad and 
the room heated to a high temperature. 

Pathology. 1 — Almost enough has been said to explain the changes 
which occur during the development of a morbid state of intra-cranial 
circulation. Fothergill intelligently divides the processes which may induce 
this condition as the following: 1. It may occur as a vascular form, witli 

1 By far the most important and interesting part of the study of brain histology 
is the intricate and beautiful arrangement of the perivascular space discovered 
by Robin* and His,f and described by them as well as by Basfdan,{ Fothergill. 
and others. His demonstrates the existence of these small spaces which 
surrounded the vessels, than which they were several times larger. He found 
them in greater numbers in the gray substance, and thought he discovered a 
communication between the spaces in the brain and cord and certain lymph-ducts 
in the pia mater. 

The oilice of these canals which loosely contain the vessels, with which they 
have no attachment, is a most important one : for. notwithstanding the fact that 
the force of blood (particularly that which goes to the cerebrum) is moderated by 
the tortuous course of the arteries after they enter the cranium, and their com- 
plete subdivision when they are distributed over the pia mater, the nervous sub- 
stance would be little prepared without such an arrangement tor sudden and 
violent accession of blood. 

This space or cavity about all of tin 1 vessels enables them to expand to a great 
extent without any actual pressure being made upon the adjacent delicate tissues. 
When such a determination of blood occurs, the perivascular fluid is driven out ol 
the nervous substance proper, and after the hypenemia subsides, returns to the 

Spaces abou{ the vessels. 



* Compte Rendu de la Soc. Biol., Pari-. L865. 
f Zeitschrifl flir Wtss. Zoologie, Band L5. 

\ Notes to translation of llis's paper, Journal of Anatomy, vol. 1. 



16 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

increased blood pressure, and be dependent upon extra-cranial agencies. 
2. It may result from tissue alterations, in which the blood is attracted to 
the brain, or it may result from toxic agents, when the two former modes 
are combined. 

Through the cerebral ventricular connection and the spaces in the 
arachnoid Ave have reservoirs for accumulation of this fluid, when the blood 
pressure is diminished, and a loose and capacious receptacle in the spinal 
arachnoid sacs for containing this fluid when the blood pressure is above the 
average, so that the balance is generally preserved. When the harmony 
of this arrangement is disturbed, we may expect to find evidences of such 
inequality. 

Now the question of the extent to which the brain may be compressed 
without injury, is one which I think will bear more discussion than it has 
hitherto received. Not only are the present means for experimentation 
inadequate, but there are certain puzzling questions that come up in the 
most unexpected manner. The experiment of suspending the subject, 
constricting the vessels, and measuring .the blood pressure by instruments 
devised for the purpose, have been tried. Dr. Loring 1 has related an in- 
stance where the first experiment was made, and I shall use his own 
words : " I would mention that a patient of mine, the acrobat known as 
the - Champion Fly Walker,' informed me that in walking across the ceil- 
ing of a theatre, head downwards, he never felt the slightest disturbance 
in his vision, though the feat occupied fifteen or twenty minutes. This 
would go to show, also, that position did not have so marked an influence 
on the quantity of either blood or serum in the interior of the head as is 
now believed to be the case. For it hardly seems possible that the quan- 
tity of blood could be either increased or diminished to any considerable 
degree, even at the expense of the other fluids, and yet allow one to main- 
tain for so long a time such a complete control over the faculties, espe- 
cially that of coordination, as to perform so dangerous a feat, and one 
which demanded so nice an application of the senses. Be this as it may, 
1 must say 1 have never been able to see the great weight of Kellie's and 
Inn-rows' experiments with animals which were killed and then suspended 

by the head or heels, as the case might be." 

When an individual is thus suspended, we are furnished with all the 
external indications of cerebral hyperemia — the flushed face, prominent 

eyes, He but consciousness is unimpaired, and is not lost until some 

time has elapsed. This question is of interest, lor it suggests the idea, that 
perhaps after all many of the changes in cerebral function are due to the 
.-hock sustained by uerve-cells by the sudden accession of blood, and not 
bo much to the mechanical pressure exerted. 

\ lo the Value of other methods for Studying the stale of the cerebral 

circulation by gauges, watch-glasses Luted into the skull, etc., 1 am rather 
sceptical. The cranial cavity is, of corifie, a closed cavity, and the 



1 Am. Psycholog. Journ., N«'\ ■ L875. 



CEREBRAL HYPEREMIA. 77 

blood supply of its contents is modified by the pressure of the bony wall. 
Any perforation must admit the external air, and the infra-cranial blood 
is i hen circulating under an atmospheric pressure, and 1 am Btrongly 
convinced such variations as have been described are not those that take 
place in the normal state. 

I have said sufficient in detailing the causes of* cerebral hyperemia to 
explain any pathological processes, the description of which I may now 
pass over. 

Morbid Anatomy Upon removing the calvarium the observer 

will probably meet -with some if not all of the following appearances. 
Dura mater and underlying membranes injected and pink, or opal- 
escent, and sometimes quite free from moisture, resembling in thi> re- 
spect a piece of damp sheepskin. The sinuses may be filled with dark 
Mood, and the surface of the brain flattened and of a deeper color than 
normal. The convolutions may be flattened and pressed down bo that 
the sulci are defined in sharp lines, the inner surface of the convolutions 
being pressed together. The surface of the brain, as I have said, is dark, 
and if the pia mater is torn off fluid blood may escape from the separated 
vessels. Upon making sections in a transverse plane the observer will be 
sometimes struck by the appearance of a pinkish blush, visible in spots, 
which is due to staining by hrcmatoidin. This appearance, alluded to 
by Fox, 1 has been compared to spots of red sand dusted on the surface. 
The corpora striata are of a very deep red or even violet color, and the 
white matter contains small puncta which are red or dark purple. The 
vessels are generally enlarged, tortuous, and filled with cptite dark blood. 
Calmeil 3 lias presented the records of autopsies in a number of cases of 
temporary duration. He found "in three cases that the cranial bones 
were notably injected ; in three the vessels of the dura mater were con- 
gested ; in one case there was fibrinous coagulation in the longitudinal 
sinus; in one the internal surface of the dura mater was furrowed by 
capillary arborizations ; in two the cavity of the arachnoid contained liquid 
blood and bloody humidity ; in four the cerebral pia mater was generally 
congested; in three cases it was reddened by extravasated blood ; in one 
the pia mater adhered in spots to the subjacent convolutions ; in one these 
convolutions on the right side were swollen ; in four the cortical substance 
of the brain was generally injected and more or less colored by hsematosin," 
etc. etc. We therefore must arrive at the conclusion that there is nothing 
remarkably significant in regard to the seat of the congestion or its form. 
The \ iolence of the symptoms will, of course, be proportionate to the extenl 

of hyperemia, though this i> not always the rule ; and 1 have seen Ca» -. and 

I think others also have, in which profound coma and speedy death were 
preceded by unmistakable symptoms of hyperemia, Buch a- contraction of 
the pupils, etc., and after death very -light evidences of congestion were 
perceptible. Microscopical examination reveals in * > 1 * 1 cases a condition 

1 Pathological Anatomy of Nervous Centres, p. 

1 Quoted by Fox, p. .>•;. 



78 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



which lias been called by various writers " l'Etat ■ crible." This consists 
of a peculiar spongy worm-eaten appearance. Arndt says that when these 
lymph-spaces are dilated they are filled with effete material from the 
brain resembling amyloid substance or leucin, called by him hyaline. The 
perivascular spaces are very large, and openings of some size are found at 
points where vessels have been cut across. These are due to the abnormal 

Fie. ll. 




Distended Tcrivascular Spaces, with Atrophy. (Fothergill.) 



pressure made by the distended vessel and the destruction of adjacent 
nervous tissue. Calmeil, Van der Kolk, Durand-Fardel, and lately Arndt, 1 
have accounted for them as the result of oedema of the perivascular space. 
This appearance is a constant one in all brains where there has been 
continued liyperaania, and especially in the brains of drunkards. The 
bloodvessels, when not destroyed, will be found to be tortuous and varicose, 
and eoated oftentimes by a granular shining deposit. The pia mater is 
thickened, and its vessels present the appearance just described perhaps 
better than any other tissue. 

Diagnosis. — The condition in its early stages may be mistaken for 

the opposite state, cerebral anaemia; in fact, the diagnosis is always full 
of difficulties. 

An inspection of the following table may, however, furnish us with 

hints so that we may be enabled to separate cerebral congestion from 
cerebral anaemia. It will be observed that some of (he symptoms are 
closely allied. 



Virchow's Archiv, Ixifl. p. 24. 



CEREBRAL HYPEREMIA. 79 



CEREBRAL CONGESTION. CEREBRAL AN/EMIA. 

Headache (generally diffused). Headache (chiefly vertical.) 

Noises in the ears, generally "rum- Noises in the ears (generally sharp oi 

bling," or singing. short). 

Mental disturbance — loss of memory, Mental disturbance — incapacity for 

hallucination. mental work. 

Pupils contracted. Pupils dilated. 

No heart sounds, except perhaps those Pulse irritable, aortic murmurs, Bphj g- 

of insufficiency. Pulse full. mographic tracing almost straight. 

Urine not increased, generally con- Urine passed in large quantities, is 

tains urates and phosphates. clear and limpid. 

In the apoplectic, convulsive, and paralytic forms there is little danger 
of making a mistake. 

These phenomena are sometimes liable to be mistaken for meningeal or 
cerebral hemorrhages, cerebral embolism or thrombosis, epilepsy, uremic 
coma, etc. 

The apoplectic variety may be confused with cerebral or meningeal 
hemorrhage. When we bear in mind that in the former there is generally 
almost transitory loss of consciousness and motor power, that hemiplegia 
is not always present, and that marked stertor is rarely found, there is no 
room for a mistake in diagnosis. 

The other varieties of cerebral trouble, namely, embolism and throm- 
bosis, may be disposed of by calling to mind the sudden appearance of 
symptoms in the former ; its association with cardiac vegetations, and its 
permanent after-effects. 

A case of this kind presents itself to my mind. A gentleman, brought 
to me by Dr. Asch, of New York, had been told by some friend that his 
nervous symptoms were due to embolism. They were these : Three 
months before, while sitting in his studio, he lost consciousness, and fell 
over upon an unfinished picture. He was conscious of his condition, but 
coidd not help himself. The room became dark, and he " saw spots before 
his eyes." Pie recovered himself in a few minutes, and resumed his 
work. A week ago a similar attack occurred as he was crossing the street. 
but he was unable to rise from the mud before assistance came. He had 
been worried by his business, had worked very hard, and had kept irregu- 
lar hours. There was no aural disease. On neither occasion did the 
attack occur after a hearty meal. He had no heart symptoms at all. 
After each attack he recovered when he took the needed rest, and thru 
saw no evidence of permanent trouble. The suddenness of his attack 
suggested embolism, but as no paralysis nor aphasia followed, and no 
after-symptoms remained, it seemed out <>t' the question to consider this 

his disease. I made the diagnosis of local cerebral hyperemia. 

With embolism there is also generally pallor of the la.ee. and absence of 

vascular excitement. 

Thrombosis is a disease of slow and steady progress, with well-marked 



80 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

symptom?, and finally decided hemiplegia. Aphasia is also a character- 
istic accompaniment of thrombosis as well as embolism. 

Cerebral softening can hardly be mistaken for the disease under con- 
sideration, because the former is nearly always preceded by partial cerebral 
anaemia, or else some distinctly inflammatory trouble. In cerebral softening 
there is decided local pain, very intense, and never absent. Convulsive 
movements, paralysis, and other decided indications mark the course of 
the softening. 

Uraemic coma may be distinguished by its deep character, and usually 
by an examination of the patient's urine. 

The epileptic attacks of cerebral congestion resemble those of true epi- 
lepsy very closely, and in many cases we must not be too positive. There 
is, however, rarely any disposition to sleep, and the attacks are generally 
preceded by some excitement, and are not ushered in by the cry. 

Prognosis The lighter forms of this morbid condition are usually 

amenable to treatment, at least this has been my own experience. Of 
course we must be governed by the duration of the disease, the existence 
of other affections of an organic nature, and the age of our patient. If 
lie be over fifty his chances of ultimate recovery are bad, but if he has 
not passed middle life, and the condition is directly dependent upon some 
exciting cause that can be easily removed, we may express ourselves more 
cheerfully. The existence of calcareous vessels is not an agreeable cir- 
cumstance, nor the fact that he has had previous attacks of an apoplectic 
or paralytic nature. Perhaps the most grave prognosis is attached to the 
maniacal form in which the delirium is not violent nor noisy, but incessant 
muttering, and in which there is a restlessness and desire for constant 
muscular exertion. The great danger seems to be in the continuance of 
the hyperaemic condition, and the possibility of its termination in cerebral 
hemorrhage, meningitis, cerebritis, or other organic* affections. With a 
hypertrophied ventricle and renal disease the patient has little to be thank- 
ful for, and we must always give such cases a very guarded prognosis. 

Treatment Of course the first indication, after inquiry into the 

patient's habits and mode of lite, is to discover and remove the predispos- 
ing and exciting cause- if possible. The next is to diminish blood pressure, 
and restore the Losl equilibrium of the intracranial blood pressure both by 
local and general treatment. 

In the majority of cases, the most simple treatment, with attention paid 

to the patient's bad habits, will generally rejpove the condition. Absti- 
nence from alcohol in some cases, attention to the bowels, and (he pre- 
caution of keeping the head cool and the neck unconlined, are the first 

observances to be followed by the physician and patient. 

If the condition be continued, or not relieved by these means, we may 

make use of Beveral remedies, among them the bromides (F. 28, F. 6), 
ergot (F. 5), and hydrobromic acid (F. l"»). The bromides, which were, 
I believe, first used for this purpose by Clifford Albutt. and Drummond, 

promptly effect ;i diminution in arterial tension and cerebral blood pressure. 

Bias Schuhr ifi of the opinion thai they contract the small vessels, while 



CEREBRAL HYPEREMIA. 81 

Northnagle thinks their chief action is upoo the nerve cells. The bromide 
of sodium I consider the most potent of these Baits, and in doses of twenty 
grains, three times a day, we may expect the best results. It is well to com- 
bine it with some cardiac sedative when there is tumultuous heart action, 
or with some heart tonic when there is a suspicion that the heart impulse 
is not sufficient to properly drive the blood through the brain. Aconite in 
one case, or digitalis in the other, is a good agent, and may be combined 
with other drugs (FF. 1, 2). If there be much excitement, and the mind 
of the individual be irritable, chloral may be advantageously administered 
(FF. 4, 3). 

Frgot or its aqueous extract is sometimes of great benefit in these 
. Dr. Kitchen has fully described its virtues, and my own experi- 
ence is directly confirmatory of all that he has said. In doses of 5.j three 
times a day, the fluid extract may be safely administered. Squibb's or 
Bonjean's watery extract, in five-grain doses, may be given alone or in 
combination with the bromide. Should the patient be very much debili- 
tated, for this condition is not rarely connected with general debility, 
we may give strychnia, phosphorus, iron, or quinine (FF. 8, 9, 10, 11, 
12). though extreme care should be taken in deciding when they are useful 
or contraindicated. 

If our patient should not be able to bear iron, we may substitute either 
zinc or arsenic (FF. 13, 14). In the forms where this treatment is re- 
quired, viz., those where there seems to be a sluggishness of the circulating- 
blood, it is well to use this treatment instead of the bromides or ergot. 

During sudden attacks, local blood-letting is advisable, leeches being 
applied to both ears, and cups over the mastoid processes. Cold to the 
upper part of the head, applied by means of a bladder or ice bag filled 
with cold water or powdered ice, are important branches of treatment. 
I direct my patients to apply cold to the back of the neck for fifteen 
minutes, every night and morning, and find that it succeeds admirably. 

A drug spoken of before is hydrobromic acid, which I have found to be 
a valuable and powerful anaemiant. 

In the Philadelphia Medical Times of October 28, 1^7i>. the reader 
will find an article in which I first advocated the use of a solution of hydro- 
bromic acid in cerebral hyperemia. 

Dr. Fothergill in a subsequent article confirmed my views most fully, 
and I have since been gratified to find how my expectations were realized 
by ;i more extended use of the remedy. 

In small doses it acts very much as do the bromides, but with much 
more intensity. 1 \w\\' a drachm is fully equal to one drachm of the bromide 
of potassium. It differs, however, in the want of permanence of its effects, 
tin- bases of the bromic Baits seeming to favor retention. 

My own experience in it< use has been limited; but from the inspection 
of i he following cases, which are briefly sketched, its value will be appre- 
ciated. 

( ' \sr. I — IVfjga ('., aged '2 !, school-teacher in a large public school-room, 
many hours, the air of which is very impure, and towards the end o\' the 
6 



82 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

day her headache begins. " Her head seems too big for her body," face 
flushed, eyes red, respiration troubled. (This was the condition before 
the summer holidays. ) A vacation did very little good. She now com- 
plains of the same symptoms. Towards night, her temporal vessels throb; 
she has " rushes of blood." There has been some dysmenorrhea. On 
August 28, she consulted me, when I prescribed hydrobromic acid 5j> t. i. 
d. Sept. 14, entirely relieved. A menstrual period was afterwards passed 
without pain. 

( \>k II. — G. J., 31, clerk. At his desk many hours daily. Complains 
of confusion of ideas, inability to fix his mind upon his work, indisposed 
to exertion, smokes to excess, insomnia, and incapacity for work. The 
top of his head is hot, and the conjunctivae injected. HBr. 3j> *• i- d. 
Complete relief in a week. This condition had lasted several months. 

Case III Mr. D., 36, "man about town." His habits are bad; 

drinks hard, and keeps very late hours. Is being treated for syphilitic 
trouble. Has had head-fulness, insomnia, indisposition to take exercise, 
gradual loss of memory for the past ten years. He formerly masturbated. 
Very hysterical and worried about himself. There are many dysaesthesiae, 
but also evidences of head-trouble. The eyes are red, prominent, and 
watery, and the temporal vessels stand out like cords. At night his sleep 
is troubled, and it is some time before he can forget himself. His urine 
contains phosphatic deposits. HBr. 3J, t. i. d., before eating. Two months 
after (Sept. 15), perfectly well, except syphilis. 

Case IV. — Miss M. E. R., 22. Insomnia is the condition which most 
annoys this patient, and when in bed her feet become cold. " It seems," 
Bhe said, " as if all the thoughts I ever had were crowded into the long 
weary hours I pass before sleep comes." She fears insanity, and is in a 
pitiable mental state. The bromides have lost their effect. A drachm 
and a half of hydrobromic acid procured sleep the first night. 

With regard to diet and indulgence in alcohol and tobacco, tea or coffee, 
it is impossible to lay down any arbitrary rules. J may begin, however. 
by interdicting all the meats difficult of digestion, and recommending a 
non-nitrogenous diet. Veal, corned-beef, pork, and certain vegetables, 
such as cabbage, cauliflower; or nuts, spices, bananas, and other aromatic 
or f;itt\ Bubstances, are not to be thought of. Simplicity of diet is to be 
insisted upon. Meats should be broiled, roasted, or baked ; and vegeta- 
bles boiled. II" the patient's comfort is dependent upon tea or coffee, it 
would be well to permit him to indulge in them to a reasonable extent. I 
do not consider tobacco is the dangerous agent that it is often said to be. 
[f the individual be a, smoker. I think his after-dinner cigar need not be 
cut oil', and a glass or two of wine is not in the least harmful. Burgundy, 

Port, or other full-bodied \\iii«> should be given up as a matter of course. 

The abuse of alcohol ami tobacco is to be looked after and stopped, if we 
have any reason to think that the patienl has these bad habits. Open-air 

exercise ; cold baths, with friction ; or the Turkish bath, and other agents 

thai tend to improve the cutaneous circulation, do a greal deal of good, 
and are to !»<• indulged in. We must insist upon the avoidance of excite- 
ment, dissipation, and late hours and theatre-going; and ii may be well i<» 
lay before our patienl what may be the result of such imprudence. Should 

We I"' railed in to find thai the disease has manifested itself in either of 



CEREBRAL HEMORRHAGE. 83 

the forms I have alluded to (the apoplectic convulsive, paralytic, or 
maniacal), we must order perfect quiet, darken the room, and use every 

means in our power to reduce the cerebral blood pressure. 

CEREBRAL HEMORRHAGE. 

Synonyms Apoplexy. Haemorrhagia cerebria (Lat.). Apoplexie 

cerebrale; haematcencephalie; coup de sang; hsemorrhagie cerebral*- (Fr.). 
Hirnapoplexieen (Ger.). 

Definition When through disease of a vessel its walls are unable 

to withstand the pressure of contained blood, a hemorrhage takes place, 
and the nervous substance in the neighborhood may be subjected to pres- 
sure. The severity of the resulting symptoms depends, of course, upon 
the importance of the parts which may be the seat of the accident, and 
upon the extent of the hemorrhage. 

Symptoms I have already alluded, when speaking of cerebral con- 
gestion, to light forms of hemiplegia of temporary duration, which were 
dependent upon slight hemorrhages resulting from cerebral congestion. 
We will now deal with a form of cerebral hemorrhage of a more serious 
character, and it may be stated that the brain is probably more liable to 
hemorrhage than any other organ, with the exception, perhaps, of the 
spleen. 1 

Bastian has made the classification which I think it well to follow. He 
divides cerebral hemorrhage into three forms, in regard to the onset of 
symptoms: (1) The apoplectiform; (2) the epileptiform; (3) the simple, 
in which there is neither loss of consciousness, nor convulsions. The 
first may be considered as a sudden and profound loss of consciousness, 
which may or may not disappear ; but, if it does, a certain amount of hemi- 
plegia will remain. The epileptiform resembles the first, but, in addition 
to the coma, there are convulsions. As I have said, the sli)ij>le variety 
may not be connected with any loss of consciousness, the patient, perhaps, 
awaking in the morning and finding himself deprived of power, or noticing 
such a loss when some movement is attempted. 

Prodromata Cerebral hemorrhage occurs generally in individual- in 

whom some well-developed chronic trouble has paved the way. This i> 
the rule, although in many cases it may be the result of some recent dis- 
ea.se. When we come to speak of pathology and morbid anatomy, these 
general diseases, and their influence in the production of degeneration of 
the cerebral arteries, will be discussed ; it is only necessary now to describe 
the forms of expression of the preparatory stages. It is not always neces- 
sary to look for indications spoken of by HughlingS Jackson. 1 "The 
careful clinical observer considers minor degenerative changes, baldness, 
grayness of hair, the state of skin, and worn teeth. He inquires for the 
history of gout and intemperance. " 

1 Paralysis from Brain Disease, p. m. 

2 Cerebral Hemorrhage, "Reynolds' System of Medicine." 



84 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

The appearance of these individuals in whom an apoplectic effusion 
may be looked for, maybe of two kinds. 1. The thick-necked, red-faced, 
and full-blooded. 2. The fair, long-necked, or aged persons, in whom the 
radial arteries are hard, and feel very much like strings of beads or pipe- 
stems beneath the skin. The existence of renal trouble also contributes to 
the development of an arterial state which favors rupture, and Ave should 
look for other indications of this trouble. Many of the symptoms of cere- 
bral hyperemia may be precursors of those that follow cerebral liemor- 
rhage. For several days the patient may have headache, formication at the 
extremities as if pins and needles were being thrust into the skin, perhaps 
a slight anaesthesia of the arm or leg of one side ; his speech may be thick 
and clumsy, or he may drop a word here and there, and his eyes may be 
red and full of tears ; dizziness, musca3 volitantes dependent upon retinal 
extravasation, and nose-bleed may all be indications of increased blood 
pressure. These last two forerunners of cerebral hemorrhage may recur 
at intervals for some time before the actual rupture of the vessel. The 
retinal trouble may be of long duration, and is of decided importance as 
an evidence of the degenerate condition of the cerebral vessel, and should 
invariably be regarded with suspicion. An atrophy of the optic papillae 
with spots of blanching at the fundus, such as we find to be the result of 
Bright's disease, is also suggestive at times of a tendency to cerebral hem- 
orrhage. To this list of prodromata may be added vomiting and stupor ; 
but these are connected with so many varieties of brain disease that they 
may only be considered as important when occurring in conjunction with 
the trouble to which I have just alluded. A very serious premonitory 
symptom is paralysis of one limb or certain isolated muscles, which indi- 
cates organic disease. After a variable time, during which some or all of 
these antecedent symptoms may be observed, the vascular accident may 
occur. lis onset may take place in two ways: (</) In connection with 
profound loss of consciousness and suddenly. (/>) Gradually, without loss 
of consciousness. We may call the first the apoplectic attack, lis 
common history is the following, and wo may take as an illustrative case 
a mate aged 50. The patient, who is of full habit, short, red-faced, and 
corpulent, had probably led a rather dissipated life. While reading his 
paper, after an unusually hearty dinner, he suddenly fell to the floor in an 
unconscious condition; his breathing is stertorous, Ihe checks and lips 

being puffed out by each expiration; his face is dark, or perhaps very 
pale, ih«- pupils dilated and insensible to light, and his eyeballs are fixed, 
turned upward, and drawn to one side, [fthe nostril he tickled no reflex 

movements follow, and the same is the case if the soles of the feet he 
titillated. lie is limp, and lies upon the floor in an inanimate heap; the 
pulse will be found to he hard and full, hut not very rapid, and if his tem- 
perature hi- taken it will probably not c\cccd !>7' , or perhaps is half a 

degree lower. He is taken up and placoifl in bed, and after a while may 

make BOme Slighl Voluntary movement with the limbs of one side of the 

body. Il will he seen that the others are without, power, for if the leg or 

arm of the paralyzed side be lifted and released it will fall to the bed as 



CEREBRAL HEMORRHAGE. 85 

a dead weight. After an hour or two, tickling of the sole of the unaffected 
foot will be followed by a drawing up of the sound leg. The eyes are 
still rolled up and turned away from the paralyzed side of the body, and 
the edges of the irides are covered by the inner canthus of one palpebral 

commissure, and by the outer canthus of the other. The eyeballs may 
be sometimes slightly agitated by a feeble movement of a nystagmic 
character. It Mill be found, on removing the patient's clothing, that he 
has unconsciously voided his urine and feces. This condition may last for 
a few hours, the coma remaining profound, and the temperature rising lo 
103 to 105 degrees, and the pulse advancing, when death takes place ; or 
it may be followed in an hour or two by slight signs of returning int (dili- 
gence, an increase of temperature, say to 100°, with slight abatement of 
the regular respiration, disappearance of stertor, and the unnatural devia- 
tion of the eyes, when his temperature may return to the normal standard, 
and the patient so far recover consciousness as to be able to recognize 
those about him, and express himself by simple words, as "yes" or "no." 
The urine has to be drawn for a day or two, and the bed-pan used, as the 
bladder and rectum are implicated. 

This form of cerebral hemorrhage may be connected with an epilepti- 
form attack in the beginning, and the convulsion may be either confined 
to one side or be general. It would be well, before going further, to dwell 
upon certain elements of the apoplectic attack and analyze the symptoms. 

THE PSYCHICAL DISTURBANCES. 

Sudden compression of the cerebral mass is always attended by uncon- 
sciousness, but it is a curious fact that slowly developed growths, such as 
large tumors or abscesses, seem to accommodate themselves to the sur- 
rounding tissues, so that sometimes no loss of consciousness occurs what- 
ever. I have seen a large abscess occupying an extensive tract of one 
hemisphere without producing the least loss of consciousness. The large 
effusions which produce unconsciousness are, in the opinion of Mr. Hutch- 
inson, 1 productive of the psychical condition, by inducing anemia of 
other parts through sudden pressure. Small clots are undoubtedly pro- 
ductive of suspended consciousness, by cutting off cither a large vessel, or 
by injury to some important sensory ganglion at the base of the brain, Buch 
as the corpus striatum. 

Consciousno>> is cither restored through the re-establishment of the 

blood supply or tin 1 subsidence of shock, except where the hemorrhage 
has taken place in the medulla. 9 



1 London Hospital Reports, vol. iv.. 1867. 

2 The variation in the loss of consciousness i> of great importance to the physi- 
cian, especially in regard to prognosis. In severe Cases there may he slight 
improvement in this respect. The patient's intelligence returns to such a 
degree as to inspire his friends with some degree of hope ; hut there is often a 
sudden relapse to the original state o\ coma, dependent upon fresh hemorrhage. 



86 DISEASES OF THE CEREBRUM AND CEREBELLUM. 



RESPIRATORY DISTURBANCES. 

Stertor is an important symptom, and should always be looked upon 
with alarm. It is indicative generally of some lesion of the base, and 
nearly always lasts until death, if there be a very large effusion, but dis- 
appears after a few hours if recovery is to take place. Respiration under- 
lie- very decided modification. Hughlings Jackson, 1 in speaking of 
disturbed respiration, says : "Again, not only is the rate of respiration to 
be considered, but the character of the respiratory movements are to be 
noted. As they quicken in rate, so do they become more extensive in 
range, though such respiration is still short. Thus in the first stage there 
may he only quiet action of the diaphragm, but at length the sides of the 
chest evert strongly in inspiration, the abdominal movement being less 
obvious, and at length the upper thorax takes part in the process. In 
-eve re cases the epigastrium sinks in during inspiration. This is probably 
partly owing to elevation of the attachments of the diaphragm from in- 
creased action of the sides of the thorax, and partly to pushing down of 
the diaphragm by increasing bulk of the lungs from congestion or oedema." 

CONDITION OF THE EYES. 

Prevost, 2 Vulpian, Lockhart Clark, and others were among the first to 
call attention to a peculiar diagnostic point which, though not always pres- 
ent, is of great value when it occurs. This has been known as " conjugate 
deviation." During the apoplectic condition the eyes of the individual 
will be fixed, so that they look upwards and outwards, towards tin 1 side 
of the Lesion, and away from the paralyzed side of the body; the only 
exception being when the lesion is in or behind ♦the pons. It is more 
often -fen when the attacks are sudden, and it is a phenomenon of short 
duration, lasting al the most but a few days. During sleep the condition 
subsides, and the eyeballs are restored to their normal state, but imme- 
diately <»n awaking they return to this position, and in spite of the pa- 
tient's effort the axis of vision cannot be changed. When the etl'iision 
is a large one, or when the onset is epileptiform, the pupils are at lirst 
very wildly dilated; but when there exists a, lesion in the pons the pupil 

which corresponds to the side of the lesion is greatly contracted. Unequal 
dilatation, however, is not of very great diagnostic value. If a, lesion in 
the pon- he extensive, both are contracted. 

TEMPEE \ti BE A.ND PULSE. 

Thanks !<• Bourneville, 8 we are enabled to st\n\\ systematically the 
variations of temperature. He divides the cases into four groups: 1. 

' Op. cit., p. 548. 2 Gazette Hebdom., Oct. 18, 1865. 

Etudes cliniques el thermometriques sur les Maladies du Systeme nerveux, 
Paris, 1872. 



CEREBRAL HEMORRHAGE. 87 

Copious cerebral hemorrhage, rapidly fatal, and attended by lowered Tem- 
perature. 2. Cerebral hemorrhage, terminating fatally in from one to two 
days, in which the temperature is primarily lowered and afterward height- 
ened. 3. Fatal cases in which death takes place in from two to Bis day-. 
In these, as in other forms, there is at first depressed temperature, next a 
return to the normal standard, with slight variations, and finally a decided 
rise. 4. Favorable cases, in which there are the primary lowering, a sec- 
ondary rise, and final return to the standard of health. 

These variations in temperature range between 9G and M)8 degrees 
Fahrenheit (rectal temperature). The pulse variation bears but slight 
relation to the fluctuation of the body heat. In the four classes spoken 
of, we may consider in the first, that the pulse is full and slow, ranging 
from 55 to Go. With the rise of temperature which characterizes the 
others, it becomes greatly accelerated, beating oftentimes 120 or 13<> per 
minute, losing its full character, and becoming small and irritable, and if 
death occurs, grows gradually weaker. If recovery follows the attack, 
there is a gradual return to its normal rate. Of course, this must be a 
very unsatisfactory consideration of the state of the pulse, for the apoplec- 
tic condition is not always the same, collapse and reaction varying greatly 
in regard to their occurrence and duration ; so the pulse, as well as respira- 
tion and temperature, undergoes many irregular modifications. 

ATTACKS WITHOUT LOSS OF CONSCIOUSNESS. 

The other form, in which the individual preserves his consciousness, is 
not so serious a condition as that just described. The person may present 
some of the premonitory symptoms already mentioned, or, on the other 
hand, may receive no warning, but while engaged in any ordinary occu- 
pation may suddenly find one-half of his body to be paralyzed, and be un- 
able to communicate with those about him, there being slight aphasia. 
With the paralysis there may be anaesthesia. This state of affairs may 
begin during the night, and on awakening in the morning he may find it 
impossible to leave his bed. The paralysis is sometimes gradual, the loss 
of power affecting one member, and afterwards the other, an unexpected 
feebleness being suddenly noticed as he is about to perform some act. One 
of my patients, an acrobat of dissolute habits, while preparing tor the 
performance, found, when he attempted to put on his tights, that his right 
leg was quite powerless; he made an effort to stand, but became dizzy, 
and grasped for support a pole that was near. After repeated efforts to 
dress lie abandoned the attempt, summoned assistance, and was taken 

home; the same night the right upper extremity was affected. lie had 
never had any previous warning. Attacks of this kind may he the fore- 
runners of others of a more serious nature. In illustration, may be men- 
tioned the ease of S. ('., a married woman, aged 11. She was drawing 
water at a sink, when she became suddenly giddy, and had to take hold of 
the banisters to steady herself. She stood thus until some friend- put 
her into a chair and carried her to her room. She sat there that day, and 



88 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

was helped to bed. but did not discover her paralysis until next morning. 
Was not unconscious at any time of the attack. Her paralysis, when she 
discovered it, was somewhat worse than it is at present, and she could not 
speak as well as she now does. A few days after the attack she went to 
a hospital, where she remained one month. She entered the Epileptic 
Hospital July 6, 1875, and was put upon strychnine and belladonna, there 
existing an inability to retain her urine. I take the notes of her subse- 
quent history from the case-book of the hospital. 

" Sept. 22. At 7.30 last night it was noticed that she could not speak as 
well as formerly. It was quite difficult for her to speak so as to be under- 
stood. She laughed a little immoderately at her inability to clearly enun- 
ciate the words. 

" An hour afterwards, in attempting to leave her bed, she fell, and since 
then has been scarcely able to speak, and can only say a few words. No 
other symptoms were noticed. Her strength of muscle and sensibility 
seem unaffected. She cries now continually, and seems to be depressed 
because she cannot speak. 

" Oct. 13. Patient can tell her name, and can name every article shown 
her. A little thickness in articulation. 

" Pupils react well. Lenses of eyes are a little opaque — the left a little 
more than the right. Face palsy almost passed away. Lower facial 
muscles act well. Sensibility in face fair. Tongue points slightly to the 
right. 

" Voluntary motion abolished in right upper extremity, the least motion 
in shoulder excepted. Articulations are all flexed in the right upper 
extremity, and the contracture is greatest in the hand, the lingers almost 
touching the palm. Elbow and shoulder are less rigid. 

"Extension is not painful, and there are no spontaneous pains in arm. 
Sensibility to contact in hand good. On finger tips feels the points of 
SBSthesiometer al three millimetres. There is no numbness in hands. Pa- 
tient considers the paralyzed hand the warmer of the two. Between index 
finger and middle finger of right hand in three minutes' time the tempera- 
ture is 98°. Same place on left hand in three minutes' time temperature 
i~ 98£ . Righl lower extremity, no motion in toes and ankles, consider- 
able motion iii knee and hips, no numbness, no contraction. 

\n interesting feature of this case was exaggerated emotional disturb- 
ance, which is usually quite marked in right hemiplegia." 

Tin: RESIDUAL PARALYSIS. 

A paralysis, remaining :\\u-v the "apoplectic Btroke," is generally uni- 
lateral, though in rare eases, where the pons is affected at the central 

portion, the paralysis may exisl on both Bides of the body ; this one-sided 
paralysis is known a- Hemiplegia^ and maj^Jje complete or incomplete as 
tion mid motion. When we examine our patient after the 
immediate j mptoms bave i" -<>nir degree subsided, \\<' will find the 

Limbs of one side limp, powerless, and generally without sensation; the 



CEREBRAL HEMORRHAGE. 89 

face paralyzed on the same Bide, and its other half drawn up by the healthy 
muscles, as their antagonists are unable to perform their functions. If the 
patient be sensible enough to put out his tongue, it will point to the para- 
lyzed side, while the eyes, if conjugate deviation exists, will turn in an 
opposite direction in a manner already described. 

Gastrowitz 1 has called attention to a peculiar symptom, the tendency of 
the patient to slip out of bed on the unaffected side. This is caused by 
the inability of the paralyzed limb to support the weight of the sound part 
of the body. lie also alludes to the fact, when pressure is made on the 
saphena nerve, at the point where the vastus externus makes a groove with 
the vastus interims, that the cremaster muscle on the paralyzed side will 
not draw up the testicle, which is not the case on the other side of the 
body. In other forms of paralysis, to be hereafter described, there is not 
the same uniformity of symptoms, there being perhaps paralysis of special 
cranial nerves, or those of the muscles of the face on the side opposite to 
the body paralysis. This variety has been called cross paralysis. Both 
sides of the face or both sides of the body may be involved, in which event 
there is a speedy fatal termination. Occasionally the muscles of the 
pharynx may be paralyzed, and sometimes the larynx. A case of this 
latter kind is reported by Luys. 2 He mentions the case of " a woman who 
had a sudden attack of apoplexy with hemiplegia of the left side, but with 
no disturbance of sensibility or of the organs of special sense. The con- 
gestive phenomena of the onset being calmed little by little, the patient 
regained consciousness, and stated that four years previously she had been 
struck for the first time with left hemiplegia, and since then had been 
aphonic. Her intelligence was good, and she spoke distinctly, but in a low 
voice. She had no paralysis of the tongue, the soft palate, or the lips. A 
few days later, she was seized with new congestive symptoms, and died 
insensible." 

This laryngeal paralysis is undoubtedly a much more common affection 
than it is generally supposed to be, and the probability is that many of 
the cases reported as aphasic are in all probability simple aphonia. Our 
patient, after his return to consciousness, will then be found to be hemi- 
plegic, and. if he is amused and attempts to laugh, we will plainly notice 
facial distortion which follows any such efforts. The surface temperature 
of the paralyzed parts is usually higher than on the other side, and the 
limbs may seem to be of greater contour. This appearance has been 
noticed by Ilitxig, 3 who, in referring to Charcot's cases, presents -even of 
his own. in all of which there was incomplete dislocation of the head of the 
humerus, with irregular pains of the arm, increased by pressure. The 
paralyzed arm was swollen, warmer and more moist than its fellow, and 
the pains alluded to began about six weeks after the apoplectic attack. 

1 Berliner Klin. Woch., Aug. 2, I - 
- I.:i France M6dicale, Sept, 28, 1 3 

3 Yirchow's Archiv, .\l\iii. p. 345, 



90 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Hitzig is of the opinion that this condition of affairs is not directly de- 
pendent upon the central lesion. Voluntary power is lost in proportion 
to the extent and situation of the lesion. Should it be in the corpus stria- 
tum, a very small lesion may produce very decided impairment of motility, 
while such is not the case in the white matter of the hemispheres. It will 
generally be found necessary to draw the patient's urine for a few days, 
for the bladder loses its expulsive force, and, if this procedure be not re- 
sorted to, there may be incontinence. Electric contractility seems to be 
exaggerated at first in the paralyzed limbs, and a very weak electric cur- 
rent may provoke the most energetic contractions. In certain cases there 
may be an increase of reflex excitability and tactile sensibility. Sensa- 
tions may be even sometimes reversed, warmth being felt as cold, or 
vice versa, or, as in the case quoted by Bastian, 1 a warm object may be 
appreciated as a weight. "A hot body on the face was recognized as 
pressure only ; on the arm it was felt as such, though the sensation was 
not distinctly localized, whilst on the left leg the same hot body was recog- 
nized correctly as regards situation, though it gave rise only to a feeling 
of tingling." I have often witnessed hyperesthesia of the paralyzed limbs, 
which were often very tender to the touch. Anaesthesia generally exists, 
however, and electro-sensibility is greatly diminished. At the end of a 
few days it is not uncommon to find marked rigidity of the paralyzed 
limbs, increased reflex excitability, and other evidences of slight cerebritis 
at the seat of the clot. Gradually there is a return to the normal condi- 
tion, and articulation, which was imperfect in the beginning, may become 
more distinct, or, should there be aphasia, the patient will begin to com- 
mand a greater number of expressions. A week or so passes, and he is 
able to protrude his tongue in a much straighter line than before, while 
the paralyzed muscles of the face slowly recover their lost power; but 
when the levator palpebrse is paralyzed and ptosis ♦results, restoration is 
much more slow. In regard to this paralysis, Bastian lias reminded us 
that very often deformities exist, such as the absence of teeth on one side. 
which may produce an appearance of facial paralysis, when in reality none 
exists. This IS seemingly a trivial matter, but its neglect is likely to lead 
to grave errors in diagnosis and prognosis. As months go by, gradual 
amelioration of the patient's condition takes place, I he limbs regain their 
power, the leg first, and finally the arm, and the patient may he at first 
able to move his toes, then to raise his leg, and, when he leaves his bed, 
gradually begins to acquire power of locomotion. The walk of the hemi- 
plegic is not to lie mistaken ; his gait is shuffling, the foe of the boot is 
dragged Over the ground, and tic leg thrown outwards and forwards, the 
knee being Stiff, and the arm is swung helplessly by the side. As the gait 

improves, and the patient gains more control over his limbs, he is able to 
perform movements which require (he action of the muscles of the hip- 
joint, knee-joint, and finally the ankle and foes. Should the patient only 

1 op. cit., p. 128. 



CEREBRAL HEMORRHAGE. 01 

partially recover, numerous secondary conditions may follow, as results of 
non-improvement of the cerebral condition. These are chiefly of a noto- 
rial character, and consist of spasms, permanent contractures, atrophy, 
and inflammations of* nerve-trunks. Such sequela may be called — 

THE POST-PARALYTIC STATES. 

I may enumerate these as — 1. Permanent contractures' ; 2. Trophic 
alterations; 3. Tremor (post-paralytic chorea of Mitchell and Charcot) ; 

and, 4. Slow clonic spasms (atheotosis of Hammond). 

Of 32 cases of old hemiplegia seen by Bouchard' at La SalpStriere, in 
31 there were paralytic contractures. The other case presented what he 
called Vhemiplegie Jlasque. This form is of slow appearance, and affected 
in the beginning the muscles of the forearm. The fingers were flexed, and 
the forearm was pronated and flexed on the arm, and at the same time the 
humerus was drawn to the trunk. 

According to Strauss, 3 this form presents several variations, and some- 
times the hand is brought in contact with the trunk, either on its palmar, 
dorsal, or radial aspects. Of a large number of cases that have come 
under my observation, I have found that deformities of the upper extremi- 
ties are much more common than of the lower; the fingers are commonly 
flexed and rarely extended, while the muscles of the trunk seem to be 
exempt from this change ; and, indeed, I cannot call to mind a single in- 
stance of this kind. Contractures of the muscles of the lower extremities 
are apt to produce deformities which resemble talipes, equinus varus or 
valgus, and the toes are flexed upon the sole. Contractures of the facial 
muscles are quite rare, and of late appearance. The deformities are 
always quite striking, because of the antagonistic action of unaffected mus- 
cles, and usually no amount of force can overcome them. Trophic changes 
are by no means rare, either in connection with contractured muscle- or 
alone. I have now several patients under observation who are hemiplegic. 
In one of these the skin of the paralyzed hand is white and puffed up : the 
heads of the phalanges and metacarpal bones are reduced in size, so that 
there is no enlargement at their points of articulation, and a consequent 
depression exists. In other cases there is considerable muscular atrophy 
to be witnessed in the palm of the hand; and in others, the hone- of the 
arm are greatly diminished in size, and the interossei quite wasted away. 

Charcot 3 has written extensively about a form of neuritis following 
cerebral lesions, which is supposed to be of a central nature. That ascend- 
ing (from the periphery to the centre) neuritis sometimes takes place after 
cerebral hemorrhage there can be no manner of doubt ; and in one case, 
at present under observation, the neuritis began at several different peri- 



1 Strauss, dee Contractures, Paris, 1875, p. '<;. - Op. <it. 

* Lecons but lea Maladies, etc Fasc. I, and previous articles. 



92 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



pheral points of the nerve, and there were consequent atropine muscular 
chaug 

Various irregular movements of partially paralyzed limbs are by no 

means uncommon. Dr. Gowers 2 presents the following excellent table, 
which embraces all the disturbances of motility which may occur after the 
hemiplegic attack. 



rOST-HEMIPLEGIA DISORDERS OF MOVEMENT. 



f Tremor 



Quick, clonic spasm, of 
intermitting type; 



mobile .spasm, of 
remitting type 



Tonic spasm, varying 



C Regular (continuous, or ou movement) 



L Regular (continuous, or on movement) 



C Continuous = ;< Athetosis" 

tOn movement = slow, cramp-like inco- 
ordination 

f Of interossei, conspicuous 



Fine. 
Coarse. 



J 



Certain, regular move- 
incuts due to interos- 
sei, pronators, etc. 

Ckoreoid f Continuous 
| spasm, or 
•{ inco-ordi- 
| nation of 

Jerking L movement. 



Spastic contracture" of 
hemiplegic children. 



Fixed rigidity, unvarying L Of flexor lougus digitorum, conspicuous = late rigidity. 

The will does not always retain its control over the affected muscles, 
though voluntary power exists usually to a variable extent, and the motor 
troubles are generally unilateral; still there are rare exceptions. The 
influence of the will generally increases spasmodic movements. Spasms 
and tremor affect first the smaller muscles, while tonic spasms affect the 
larger muscles of the limbs. One form of tremor of a post-hemiplegic 
character has been called by Mitchell "post-paralytic chorea;" the tre- 
mor is BUggestive of sclerosis and may begin within a period ranging 
from one to several months, affecting generally the upper extremities. It 
jgravated by any exercise of volition. It. may affect both extremities, 
but very rarely the face, and the movements are quite coarse, and may be 
associated with a certain amount of hemi-anaesthesia. A variety of move- 
ment of a clearly post-hemiplegic character has been elevated to a, distinct 
position, and given the name " atheotosis" by Hammond. As this con- 



1 These trophic changes are of a most interesting nature. Duncan* found in 
one ease that an eruption had appeared on the thigh of the paralyzed side which 
disappeared with the return of power ; and Charcoxf and Payne J another. In 
a case mentioned by the former, a vesicular eruption appeared, which followed 
the distribution of the superficial ramifications of the peroneal uerve, and was 
coincident with the hemiplegia. In this case the hemiplegia followed embolism, 
and a branch of a spinal artery (rami medullas spinales, of Rttdinger) was found 
obstructed bj a plug. Pressure had been madQ on tin' spinal ganglion from 
which "ne of the branches of the sciatic originates. 
Med. < Ihir. Trans., vol. Ii\. 



* Journ. of ( utaneou Mi d., Oct . i s <'> s . p. 69 ; q id bj Charcot. 

i Op. clt., ; % |{l - Ml,L Journ., A.ug. L871. 



CEREBRAL HEMORRHAGE. 03 

dition is ordinarily a secondary affection to other neuroses as well as 
hemiplegia, the undue prominence which it has received is entirely unde- 
served. °Gowers says: " Neither clinical history nor supposed pathology 
of atheotosis affords ground for separating it from other forms of disordered 
movement commonly seen after hemiplegia, but any one of which might 
occur in the primary affection." Charcot 1 refuses to acknowledge it- dis- 
tinct character. He presents several cases, all of which followed BOme 
form of hemiplegia; and the literature of neurology is replete with exam- 
ples of so-called atheotosis which are generally connected with hemiplegia, 
chorea, or even hysteria. I have myself seen a case of the latter kind 
which disappeared spontaneously in a few weeks after its appearance. 
This form of movement is considered by Hammond to consi>t of a spas- 
modic agitation of the fingers, and is "characterized by an inability to re- 
tain the fingers and toes in any position in which they may be placed, and 
by their continual motion." 

The following case is one of post-paralytic chorea, connected probably 
with embolism, and with a certain amount of neuritis of a very painful 
character :— 

Jane C, 35 ; Ireland; single; domestic. Entered hospital May 22, 

187G. Family history good, as far as known by the patient. She states 
that her health has always been good, with the exception of an attack of 
rheumatism a year ago. Two weeks ago, while dressing, she fell, and 
thinks that she remained unconscious for eight minutes. On recovery she 
was unable to use her right hand or leg, and was placed in bed. where she 
remained for seven days. She vomited everything taken into the stomach. 
She was brought to the hospital a few days ago, suffering from paralysis 
of the right side, which was complete and affected both limbs. There was 
some rigidity, decided headache, and paralysis of the muscles supplied by 
the porta dura upon the right side. She was intensely emotional, and 
moaned and cried. 

July 12. Patient has been quite sick for the past four weeks. There 
have been high evening temperature, abdominal tenderness, diarrhoea, and 
Other evidences of typhoid fever. She has been kept on milk diet, with 
quinia and stimulants. 

Aug. 18. Patient has improved somewhat. She is very weak, but able 
to go aboul the ward. The hand and forearm of the right side are rather 
rigid, and the lingers are flexed, but it is possible to extend them. Pa- 
tient still emotional, and cries readily when excited. There is decided 
tremulousness of this extremity. Tain in the shoulder, which shoots down 
the arm. These pains are more intense at night. Aphasia disappears. 

Nov. 2:5. The patient's hand shakes whenever any voluntary movement 
is made. She cannot feed herself, for when she takes up her fork or spoon 
she cannot carry food to her mouth. The pains are >till severe, and seem 
Centered more in the shoulder. She can move her right arm nearly as 

well as the left, but cannot hold any large object placed therein. Exami- 
nation of heart revealed a heart murmur, with second sound heard with 
greatest intensity over aortic valves, and not transmitted in either direc- 
tion. A murmur is also heard with firsl sound, which is transmitted into 
the carotids. There are probably both aortic BtenOfiis and insulliciencv. 

1 Op. cit.. 1th part. p. 455. 



94 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Oct. 1*77. The patient is still in the hospital. Complains now of diz- 
ziness and disordered vision, which is not dependent upon any structural 
alteration. The right arm and hand are much more quiet than they have 
been. There is very little of the tremor which was at first coarse, but 
rhythmical. She can now execute a variety of acts, but an especially 
delicate operation is attended with aggravation of the tremor. 

Causes Any agency which favors a degeneration of cerebral vessels 

leads to the occurrence of hemorrhage such as I have just described. The 
list of Buch causes is therefore a long one. Among the many formidable 
diseases, Leading to that which forms the subject of our remarks, are those 
of the heart and kidneys. Hypertrophy of the left ventricle, Bright's 
disease, and local disease of the arteries with deposits of atheromatous mat- 
ter, or obliteration of vessels by softening, pressure made by tumors, and 
through other diseases of the brain, may be mentioned as influencing the 
causation of cerebral hemorrhage. Cerebral hemorrhage is an affection of 
advanced life, though cases are on record among children. A careful 
inspection of the records of a great many cases discloses the fact that the 
majority are between fifty and sixty. With the advance of life and cor- 
responding impairment of vitality, the arteries become rigid, the heart hy- 
pertrophied, ami the general vascular system undergoes important changes. 
I have already alluded to the annular and hard character of the arteries ; 
the arcus senilis, which consists of a small whitish circle which may be seen 
overspreading the iris, may be mentioned in addition as a suggestive sign. 
The color of the face is dusky red, and many of the capillaries of the skin 
covering the cheeks and nose are quite tortuous and dilated, and present 
minute varicose enlargements. As to inheritance of an apoplectic ten- 
dency. I fully agree with Hughlings Jackson, that the only heritage trans- 
mitted from lather to son is the liability to arterial degeneration, gout, etc. 
This exception to the general rule is somewhat conspicuous, for the here- 
dition of many convulsive and neuralgic, as well as the trophic diseases, 
is a well-established fact, and has long been recognized as an important 
etiological factor. Cerebral hemorrhage, as I have stated, is by no means 
confined exclusively to adult life. Numerous observers have called atten- 
tion to cases which have occurred among M-vy young children, though, 
in these instances, injury has generally produced the accident, especially 
such mechanical causes as convulsions, anaemia, etc. And now regarding 
the predisposing states which favor the rupture of a vessel. An hypertro- 
phied heart, enlarged by overwork in forcing the overloaded blood which 

inii-i be formed when ihe kidneys do not properly act as eliminants, is the 

firsl factor of the disease. With this condition of affairs the small vessels 
musl necessarily !»«• subjected to abnormal strain, and consequently under- 
go such changes as thickening or aneurismal dilatation, or even actual 
destruction. The arterial changes, ofwhicl) I will more fully speak when 
we come to consider the pathology <>f the disease, an' fatty degeneration, 
aneurismal dilatation, and calcification. These c Litions are produced 

by alcohol, and improper diet, such ;is continued indulgence in fatty food. 

\ ledentan life, connected with greal and protracted intellectual strain, 



CEREBRAL HEMORRHAGE. 95 

as well as such diseases as rheumatism, syphilis, and other chronic mala- 
dies, enter the field as predisposing causes. Season appears to have some 
influence in the production of cerebral hemorrhage, the majority of 
cases occurring in winter. As to exciting causes, their name is Legion. 

Straining at stool, coition, violent muscular effort of any kind, the indul- 
gence in stimulants, and in fact any agency which cither promote- an ab- 
normal blood supply to the brain, or prevents its return, will have the 

effect, should there be disease of the vessels, of producing rupture. I 
have taken from my case-book data showing the exciting causes in a num- 
ber of cases, and the time of the attack : — 

Lifting a heavy weight, or other muscular effort . 12 

Excitement (alarm of fire) ..... 1 

Drawing water ....... 1 

Falls 4 

Fright ......... .'! 

Thrown down by husband ..... 1 

Head injuries ....... 8 

Straining at stool ....... 2 

Xo history of cause ...... 20 



Time of Attach — At night, in 30 cases; during the day, in 22 cases. 

The fact that the large proportion of these attacks occur at night, is an 
interesting one. They were mostly hospital patients, and some were irre- 
sponsible ; so, of course, their statements are to be taken with allowance 
One woman said : " I awoke in a fright, and in attempting to rise found 
I was unable to do so." It is probable, therefore, that the condition was 
dependent upon disturbed cerebral circulation connected with nightmare; 
but in opposition to Hammond's statement that the occurrence of the hem- 
orrhage during "healthy, undisturbed sleep" is unlikely, I will state that 
nearly every one of these thirty patients found that they were paralyzed 
only when they awoke in the morning, and attempted to get out of bed. 
Exposure to the sun's rays, and the stoppage of any flux that is either 
normal or pathological, are often sufficient to produce an attack, and as an 
example of the latter hemorrhoidal bleeding may be mentioned. 

Hemiplegia may be a result of variola ; and tin 1 following case, in which 
epilepsy and hemiplegia dated from smallpox, possesses much interest. 
The paralysis was due undoubtedly to an epileptic seizure, during which 
some vessel was ruptured. 

M. J. T., 35 years, born in New York ; no occupation : entered the 
Epileptic and Paralytic Hospital Feb. 11. Is7<>. Mother died of con- 
sumption; sister had epilepsy. Firsl fits appeared at the age of five years ; 
came on about three months after an attack of smallpox ; hemiplegia of 

the right side came on at the same time, she belie\ e8, as the epilepsy. 

Before the convulsions she has cramps in the paralyzed arm and hand, and 

a feeling of dizziness; the attack- oceni- mosl frequently in the daytime. 

three or four together, and recur once in three or four weeks. But shorth 



96 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

before her admission she had them nearly every day. Circumference of 
skull. 20| inches; antero-posterior measurement, 13 inches; transverse, 
13 inches; memory good, mind rather weak; speech good, sight good, 
hearing fair with left ear ; cannot hear with right ear, even when the 
watch is pressed against it. Sensibility to pinching and pricking appear 
entirely abolished on the right side from head to foot. Drags right leg in 
walking; has but little use of right arm and hand, the muscles of which 
lane a tendency to spasmodic contraction; temperature somewhat dimin- 
ished on right side ; appetite fair ; bowels rather costive. Menstruated at 
13 years, and has been regular since. 

Present condition, June 1, 1<S7(5 : — 

Memory appears to be very good ; the fits have decreased in severity 
and in number. Had but two attacks last month ; none at night. Has 
haemoptysis sometimes before the attack, and an aura of about a minute's 
duration; flexor of muscles of right hand is contracted; thumb is turned 
again, so that its inner part touches the under part of the index finger; 
lastly, the whole hand is somewhat drawn up, and lies in her lap with the 
palmar surface up. When directed to put hand up to shoulder, it shakes 
right and left ; this shaking is very violent, but only so when she makes 
voluntary movement. It is, however, entirely quiet while in her lap. 
Has the irregular hemiplegic gait ; protrudes her tongue straight ; eyesight 
good ; hears perfectly well. There is facial paralysis (peripheral) on the 
side opposite the hemiplegia, but no ptosis. 1 

Morbid Anatomy and Pathology A vessel impaired by dis- 

. and subjected to even the normal blood pressure, will very soon 
sutler changes in its calibre, insignificant perhaps at first, but afterwards 
far more serious. But, when the blood pressure is abnormal, and a force 
is exerted which the resilient character of the vessels enables them to 
withstand in the healthy stale, the weakened portion gives way, and the 
brain-substance in the neighborhood is subjected to dangerous pressure. 
The character of the loss of function depends very nluch upon the import- 
ance of the vessels and their areas of distribution. The middle cerebral 
artery i> especially liable to rupture, being in direct communication witli 
the left side of the heart; consequently, the corpus striatum, optic thalamus, 
and parts supplied by this artery, suffer injury. The Other large \ essels 
follow next, and may be affected in various parts of their course. The 
diagram I present (Fig. 12) illustrates the topography of brain-lesions, and 
will enable the reader to see how certain hemorrhage may destroy the func- 
tion of various important nervous tracts, the symptoms being displayed 
generally on the Opposite side of the body, bill occasionally on the same. 
In our future Study of the localization of lesions, we are to bear in mind 

lie physiological experiments of Broca and Brown-Sequard, and the later 

1 Ajb an illustration of a curious cause, Eulenburg* relates the case of a switch- 
tender who, during a heavy thunder storm, inserted an iron key in the lock of a 
switch-signal, lie was suddenly deprived of power, and fell to die ground. 
After an hour or two, when sufficiently revived by the rain, he dragged himself 
to b neighboring Btation. lie was paralyzed on the lefi side. 



Berliner Klin. Woch., April 86, L875. 



CEREBRAL HEMORRHAGE. 



97 



researches of Hughlings Jackson, Fritsch and Ilitzig, Vulpian, Vesseyer, 
Ferrier, Dupuy, Pierret, Raymond, Putnam, Carvaille and Duret, and 
others. The pathological course of cerebral hemorrhage is the following : 
1. The stage of preparation, during which the arteries undergo the changes 

Fig. 12. 




i 

A. Region of articulate speech (probably, also, slightly developed on right side as well). 
B B. Supraventricular region : Paralysis on side opposite lesion. As a rule, not as susceptible 
to dangerous iujury as parts beneath. C. Ventricular region : Lesions apt to be followed by ser ions 
motorial and sensorial symptoms. D. Sub-ventricular region : Lesions apt to paoduce paralysis 
of crauial nerves by extension of pressure. 1. Lesion in central part of hemisphere. 2 2. Cortical 
lesion, usually affecting special motor centres, or affecting mental functions. 3. Lesion affecting 
speech-centre. 4. Lesion affecting nucleus caudatus of corpus striatum. 5. Lesion affecting cms. 
6. Lesion affecting peduncular expansion. 7. Lesion affecting centre of pons. S. Lesiou affecting 
lateral half of pons. 9. Lesion affecting medulla. 

already spoken of. 2. The operation of an exciting cause, the rupture of 
the vessel, the injury of the nervous substance, and the formation of the 
clot. 3. Death, absorption, or limitation. 

Bouchard 1 and Charcot both affirm that cerebral hemorrhage is always 
dependent upon a peculiar kind of disease of the vessels. This diseased 
condition consists of a studding over with minute aneurismal dilatations 
which have been called by them "miliary aneurisms." These arise from 
a primary degeneration of the outer coat of the vessel, generally secondary 
sclerosis, and finally atrophy of the muscular coat and dilatation. Of 
sixty-five cases of cerebral hemorrhage, they found miliary aneurism in 
every instance. Both of these authors consider the vascular change to be 
different from that of atheroma, which begins in the inner coat. These 
appearances are confined to the brain, and exist when there 18 no evidence 
of atheroma to be found in any other part of the body. Notwithstanding 
that these views are endorsed by such men as Meynert, Bastian, and oth- 
ers, there are many observers who consider miliary aneurisms to be due 
only to careless manipulation, or thai they are identical with the "hyaline 



1 Archives dee Physiol., 1868. 



yS DISEASES OF THE CEREBRUM AND CEREBELLUM. 

degeneration" of Gull and Sutton which is found in other localities. 1 
These miliary aneurisms have been said to be due to "periarteritis," but 
it cannot be denied that a large proportion of cases of renal and heart 
disease produce modifications in blood pressure, which would account for 
the rupture of the vessel without any primary inflammatory condition. 

Fig. 13. 




Miliary Aneurisms. 

I have repeatedly seen miliary aneurisms, and must confess that they 
appeared to depend upon some organic change which extended over a con- 
siderable space of time. 

1 Dr. Barlow* has presented a case which fully demonstrates that cerebral em- 
bolism may produce a condition of the vessels which leads to the formation of aneu- 
risms, first causing local arteritis and weakening of the wall of the vessel. In 
this case (that of a boy aged ten years) there was right and afterwards left 
hemiplegia, and aortic regurgitation. The autopsy revealed "cortical soften- 
ing on each side of the lower part of the ascending frontal and the posterior 
parts of the second and third frontal convolutions. The clue to this condition 
was found in the middle cerebral arteries. On both sides these vessels were dis- 
eased at the spot where the fine branches were given oil' over the island of Iveil 
for the supply of the cortex. Of these branches on both sides, the one supplying 

Broca's convolution and the one supplying the ascending frontal were also dis- 
eased. There was no aneurism to he discovered anywhere, but the walls of these 
vessels presented man} small calcified nodules obvious to touch and sight." This 

calcification was not noticed in any Other vessel in the body, and emboli had 

lodged in the spleen and kidneys. In Goodh art's cases actual aneurism had fol- 
lowed the embolism, and Dr. Harlow's case demonstrates that there is a primary 
weakening, 

Durand-Farderf found thai of 82 cases the arteries were onl) healthy in !t 

Cases, while in 21 thoj were thickened, and in»*2 ossified. 

Audr.il} found thai of 82 Cases the arteries wen- apparent!) healthy in but I. 



: Brit. Med. Journal, Ap.ii ;. is;;, p. 882. 

* i raittf, cllnlque el pratique, des Maladies dea Vleillards, Paris, 1854, p. 228 t 

: < Unique Mtfd., \.,i. \. 



CEREBRAL HEMORRHAGE. 99 

Zenker differs from Charcot and Bouchard, and considers the internal 
coat to be that which is first attacked. When miliary aneurism exists, it 
is generally in conjunction with either gout, cancer, tubercule, leucocythe- 
mia, or other conditions, when leucocytes may pass into the cerebral ves- 
sels in large number. In old drunkards and general paralytics this vascular 
change is not an uncommon one. In regard to atheroma there have been 
many cases brought forward where this appearance was so constant as to 
gain recognition as one of the chief factors of the cerebral hemorrhage. An 
atheromatous artery contains deposits of a firm, semi-fatty nature, between 
its inner and middle coats. At an advanced stage the deposit is more 
calcareous and hard, and the artery may be sometimes easily broken in 
two. Occasionally the deposit between the coats, by distension considera- 
bly narrows the calibre of the vessel, and in this way forms occlusion at 
one point while at a weaker one hemorrhage takes place. The veins and 
capillaries are not so often involved as the arteries. In regard to the seat 
of cerebral hemorrhages, we find from a table prepared by Gintrac that in 
751 cases there was — 

Times. 

Hemorrhage in the meninges . . . . . . .172 

;t " middle lobes . . . . . .127 

" " pons and peduncle . . . . .70 

" " corpora striata . . . . . .72 

" " cerebellum . . . . . . .55 

" " corp. striata and op. thai. .... 48 

" " ventricles (septum and plexus) ... 46 

"' " cortex . . . m . . . .45 

" op. thalami ....... 38 

" " post, lobes .... . 33 

" " ant. lobes . . . . . . .17 

" " corpus callosiun ...... 1 

The other 21 were into the medulla and cord. It will be seen then 
that hemorrhages into the meninges and into the middle lobe of the brain 
are of most frequent occurrence. It will be well to state that large por- 
tions of both hemispheres maybe destroyed without serious symptoms: 
hut when we approach the base the danger is increased, and if the third 
frontal convolution be the seat, we find a very decided and serious result, 
which is aphasia. The majority of hemorrhages are in or about the optic 
thalami and the corpora striata, and if they be extensive the ventricles will 
be filled. If the hemorrhage be great, pressure may he made on the oppo- 
site side, or the blood may find its way into other localities. In the ante- 
rior lobes the effusion is generally circumscribed, hut from this site it may 
find escape into the lateral ventricles. In the ganglia and important 
parts at the base, the hemorrhage is generally small, hut is of the most 

serious character because of the importance of the parts it destroys. This 
is the case in the corpora striata. In the pons and medulla any consid- 
erable extravasation is followed by death or serious trouble. The shape 
ot the cavity is variable, but in the gray matter it is circumscribed, and 
in the white it is irregular and elongated. 



100 



DISEASES OF THE CEREBRUM AND CEREBELLUM 



Parrot 1 reports 34 cases of cerebral hemorrhage in new-born children. 
In these the clot was found at the inferior part of the brain; sometimes 
on the right side, but more generally on both sides. 

Should the patient survive the apoplectic attack, and die subsequently 
of some other disease, the cerebral clot will probably prove to be well 
organized, hard, and separated from the brain-tissue in the vicinity by a 
sclerosed mass. The immediate changes are the following : At the end of 
a few days the serum is absorbed, leaving the solid portion as a gelatinous 
mass ; finally the clot contracts, becomes yellow, and assumes the appear- 
ance I have alluded to. It is rare that an old clot is completely absorbed, 
but it is found encysted and firm, and, perhaps, has produced some soften- 
ing. It is not uncommon to find more than one clot in a patient who 
has had several hemorrhages. There may be a cyst filled with thick- 
ened blood, which is indicative of an effusion of recent occurrence, and 
there may be others of smaller size, in different stages of resolution. Small 
aneurismal dilations are also found, while local patches of softening, or 
cysts filled with clear serum, are not rarely present at the same time. 

A common form of hemorrhage is the meningeal. Goodhart 2 has 
written an exhaustive paper upon this subject, in which 49 cases are 
given, proving most conclusively its connection with diseased kidney and 
hypertrophied heart. Of these 49 cases, 30 were due to renal disease, and 
six had uncomplicated heart trouble. When the hemorrhage takes place 
above the arachnoid, we are assured by Mr. Prescott Hewitt 3 that the 
blood very rarely gravitates to the base ; but when the hemorrhage is sub- 
arachnoid, the blood may find its way below, thus making the condition a 
most serious one. After death a peri-cortical collection of blood will be 
found ; which is extensive over the base, and probably produces death by 
pressure upon the pons and medulla. 

Diagnosis Coincident with the occurrence of the hemorrhage, 

symptoms will be presented which will enable us *to localize with some 
degree of accuracy the position of the clot, its extent, and character. A 
lesion in or about the corpus striatum will be followed by hemiplegia of 
the opposite side. The temperature being higher in the paralyzed Limbs 
than in the Others; the eyeballs will deviate towards the side of the lesion ; 
and i he tongue, when protruded, will point to the hemiplegic side. The 
face is paralyzed on the same side as the arm and leg. A lesion in or 
about the optic thalamus will present the same phenomena., only that the 
temperature is higher in the paralyzed limb than in the preceding form. 
A lesion in our mis is followed by very much the same symptoms. If 

the under and inner part be. affected, we find cross paralysis, the face 

being paralyzed on the side of the lesion, while the extremities are para- 
lyzed on the other side of the body. 1 Ieiniana-sl hesia is quite marked ; and 
the third and seventh nerves are paralyzed, so that ptosis and profound 



1 Arch, de Tocologie, \xijy. 

* (inv's Hosp. Rep., vol. xxi. p. 1 li I . 

* Holmes's System of Surgery, i s 7< ». 



CEREBRAL HEMORRHAGE. 101 

facial paralysis result. A lesion in one lateral half of the pons is fol- 
lowed by hemiplegia of the opposite side, profound coma, deviation of the 
eyes away from the side of the lesion, facial paralysis on the side of the 
lesion, lowered temperature in the non-paralyzed limbs, paralysis of the 
muscles of deglutition, and anaesthesia or hyperesthesia of parts supplied 
by the fifth nerve. A lesion of the upper half of the lateral region of the 
pons will be expressed by pretty much all of the symptoms which follow 
the last mentioned lesion, except that the facial paralysis will be on the 
side opposite the lesion. A feature of all forms of lesions in the pons is 
the very decided character of the facial paralysis ; and if there be exten- 
sion of the lesion, there may be double facial paralysis, with hemiplegia of 
the body. A lesion in the posterior part of the pons, beside the symp- 
toms just alluded to, will produce paralysis of the fifth, sixth, and seventh 
nerves on the side of the lesion ; or, according to Brown-Sequard, it may 
sometimes produce cross-paralysis. A lesion in the centre of the pons is 
followed by double paralysis, deep coma, marked contraction of pupils 
(while in the other forms one pupil may be contracted on the side of the 
lesion), lowered temperature on both sides, with ultimate rise and but 
slight loss of sensation. Louville 1 reports a case of hemorrhage into the 
pons, in which sugar was found in the urine. This he considers to be 
an ever-present symptom of disease in the lower part of the pons, but 
never a feature of disease of the upper part. A hemorrhage in the 
medulla is followed by paralysis of the cranial nerves on both sides, bi- 
lateral paralysis of the body, and, generally, rapid death. Extensive 
lesions may produce a combination of these phenomena, and diagnosis 
may sometimes be an extremely difficult matter. A patient under treat- 
ment with syphilitic disease of the brain, presents a combination of symp- 
toms which are extremely interesting in a diagnostic sense. 

Win. McG., aged 58 years, when about 21 years of age, had a primary 
chancre upon the dorsum of the penis, followed some months afterwards 
by secondary symptoms. After a few years all traces of syphilitic trouble 
seemed to have disappeared, as he enjoyed extraordinary good health. 
He has led for the last twelve or fourteen years a, very intemperate life, 
and has regularly "gone upon sprees." Twenty-six months ago, after an 
attack of facial neuralgia, which was evidently specific, he became henii- 
plegic during one of his drinking bouts, but does not remember any of the 
circumstances immediately connected with the apoplexy. AY hen lie be- 
came sober he found that the left side was paralyzed, but the loss of 
power could not have been very great, for he was able to walk in a few 
days. About a. year ago the right side of the face became anaesthetic, and 
he began to lose the sense of taste on the left side; at the same time he 
found it difficult to arrange the food for mastication, and his power of 
articulation became embarrassed. 

Present Condition. — Eyes. Pupils of the same size, and not abnor- 
mal; respond well to light ; no ptosis, nor disturbance of vision ; no retinal 
change. Face. — No impairment <»f buccal museles, nor of superficial 



1 Gazette des BOpitaux, Feb. 8, 1878, 



102 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



facia] muscles, except slight contraction of those of right side when he 
opens his month. When this is done, the orifice is unsymmetrical. Anos- 
mia marked, taste impaired to slight degree. Warm substances produce 
an impression on sound side of tongue, but not on the other. Left side of 
the palate paralyzed, and lower than the other. Left side of tongue atro- 
phied, presenting the appearance depicted in Fig. 14; and when protruded 
the tip points to the right side, no apparent tactile loss of sensation as de- 
termined by the a^sthesiometer. Saliva is secreted in large quantities, 

Fig. 14. 




Multiple Lesion with Tongue Atrophy. 



and constantly drips from the angles of the mouth when he talks. Sensa- 
tion of right side of face impaired; feels points only when separated 3 mm. 

on other side I .', ; some difficulty of speech, especially with the letter r, 
pronouncing •'righteous" "eightshus;" the Left leg he dv.v^ slightly when 
lie walks. Six months ago he Blepl upon his arm when drunk, and thereby 
added to his other troubles a decubitus paralysis ; slight loss of power in 
both arms. 

In this case there were evidently two lesions — one in the medulla, and 
the other on the right side of the brain — one hemorrhagic, the other of 
-low grow I h. 

We are to diagnose the Bymptoms of cerebral hemorrhage in itsdifferenl 
stages from those of the following diseases^ Actual <itt<i<-L- from uraemia, 
drunkenness, opium poisoning, tumor, epilejpey, compression or concussion 
from injury, embolism, and thrombosis. There are certain general ap- 
pearancee which symptomatize the urcemic condition, and can hardly be 



CEREBRAL HEMORRHAGE. 103 

mistaken; the skin is waxy and (Edematous, the eyelids arc puffed, and 
the legs and feet swollen; but, as Bastian suggests, it does not always fol- 
low, when we find these appearances in an individual over thirty years 
of age, that the coma is always purely of an uraemic character, and that 
there may not be a complicating hemorrhage. The urine, when drawn, is 
found to contain albumen, but this symptom by itself is insufficient to 
settle the question. Uramiic coma is generally of gradual appearance, 
though Hughlings Jackson calls attention to a form which has a rapid onset, 
with convulsions; but, on the whole, such sudden appearance i> more sugges- 
tive of cerebral hemorrhage. It is nearly always preceded by prodromata 
for several days. The patient is stupid, and inclined to somnolence, and has 
headache. Bourneville has ascertained that the temperature rapidly sinks 
when the coma begins, to a point very much lower than it does in cere- 
bral hemorrhage, and continues depressed during the condition, while the 
converse is true in the other affection. Convulsions are much more promi- 
nent and constant features of uramiic coma than they are of cerebral 
hemorrhage; and, beside, there is no paralysis. Numerous other indica- 
tions will serve to make the diagnosis clear in this respect. The coma is 
not deep, and it is possible to arouse the patient, and there is great hyper- 
kinesis, there being a tendency to muscular spasm and rigidity which i- 
not unilateral. The character of the respiration differs from that of cere- 
bral hemorrhage, the stertor being more superficial. From drunkenness 
the diagnosis is not always so easily made, the two conditions sometimes 
coexisting, and it may be necessary to delay until the effect of the alcohol 
has passed away, before we can determine our patient's true condition. 
The odor of liquor, the circumstances under which he was found, and his 
imperfect loss of consciousness, are sufficient to excite suspicion. If he 
vomits, we may chemically test the substances thrown up, or we may ex- 
amine his urine. Anstie gives a delicate test which may be employed. 
If even only one drop of the urine of the patient who has taken a toxic 
dose of alcohol be added to fifteen minims of a solution of one pari of 
bichromate of potash in three hundred parts of strong sulphuric acid, the 
mixture will turn an emerald green. With a larger quantity this test will 
be much more certain. The articulation of an intoxicated person when 
aroused is so peculiar and so interrupted by hiccough that there need be 
no chance for mistake in this respect. Narcotic poisoni '//</ may resemble 
somewhat the symptoms indicating cerebral hemorrhage'. Like alcoholic 
coma, its advent is gradual, and there are convulsions, while the face is 
dusky, but the patient may be generally aroused. Much Stress has hern 
laid upon the condition of the pupil in opium poisoning a- a diagnostic 
sign; but, as this symptom is indicative of hemorrhage in the pons, it 
loses some of its value. Epileptic co, mi can hardly he mistaken (should 

it he a stage of the actual epileptic attack) for that of cerebral hemorrhage. 

In the former there is a history of com ulsions : the stupor la<ts hut for an 
hour or two at the most ; the temperature is elevated; and there is some- 
times an escape of bloody froth from the mouth. The previous histor\ of 

the patient should set all other doubts ai rest. Compression or concussion 



104 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

from head injuries may be mistaken for the condition under consideration. 
In the former there may be a subarachnoid effusion, which may give rise 
to many of the symptoms. The latter is usually of short duration, so far 
as symptoms are concerned. The skin is pale, the pupils dilated, and 
vomiting occurs at some time or other. It is always of decided importance 
that we should inquire into the nature and receipt of the injury; for, should 
it follow a fall while the patient is in a safe position, we may suspect that 
he lias had a seizure of some kind, the injury being secondary to the 
attack. 

The internal cause of the hemorrhage is always important, whether it be 
produced by an abscess, tumor, or other intracranial diseased states ; and 
these things are to be taken into account. The antecedent history of the 
patient, the presence of pain of a localized character, subsequent convulsion, 
loss of vision, aural disease, and kindred conditions should all be ascertained. 
Serous apoplexy, as it has been called, when an immense effusion of serum 
takes place either beneath the investing membrane, or in the ventricles, 
or throughout the brain substance, is usually of gradual origin, and de- 
pendent upon the collection of fluid which takes the place of atrophied 
brain substance or attenuated vessels. 

Prognosis According to all observers it is an exceedingly difficult 

matter to make a prognosis with any certainty, especially an early one, 
and, consequently, it is of the utmost importance that every circum- 
stance of the case should be taken into account and carefully considered 
before we give expression to any opinion. Certainty of prediction is made 
doubtful, by new complications, and fresh dangers that are likely to arise. 
There are several questions that are to be answered, and the first of 
these concerns the fatality of the actual attack. The character of the 
coma, its depth and duration, the appearance of convulsions, abolition of 
reflex excitability, stertor, involuntary passage of urine and feces are to 
be regarded as indicative of an early fatal termination. If this condition 
be connected with unequal pupils, and double hemiplegia, the prognosis is, 
if anything, more unfavorable. Large hemorrhages into the ventricles, cor- 
pora striata, or into the crura or pons are then to be feared. The patient 
presenting these alarming symptoms dies usually in a very short time, say 
in from a few hours to two or three days, and there may be, perhaps, an 
aggravation of the symptoms towards the end as the result of fresh hemor- 
rhage. If lie survives the attack, what are the chances for the return of 
mental power? or, if not affected, will it subsequently become impaired? 
This depends very much upon the occurrence of inflammatory action about 
the clot, or whether there be uremic trouble or softening. Wemayaugur 

well for his chances if these conditions are absent, and if he lives for eight 
or tin days after the immediate attack. In regard to the speech disturb- 
ance- : if there be simple ataxia, there is no reason to W-.w ; if, how- 
ever, any marked forgetfulness of words j>t genuine aphasia exists, the 

prognosis is less hopeful. 'This condition of affairs often exists for 

years without the slightest improvement taking place. At first the 
mind is confused and dull, and, unless the hemorrhage is the result of 



CEREBRAL HEMORRHAGE. 105 

softening or other degeneration, there is but little doubt that he will 
ultimately regain his mental activity. It is, however, well to qualify 
this statement by saying that in old people the tendency is the other way. 
Congenital apoplexies, or those occurring in early life, arc apt to Leave 
sequela? of the most deplorable description, such as imbecility and kin- 
dred conditions. The return of muscular power and normal Bensation 
is the most important question to be next considered, for much of the 
patient's future comfort depends upon the recovery of his lost power. 
Should the limbs remain paralyzed, or secondary neuritis take place, the 
consequence will be atrophy and contractures, such as I have described. 
It is, however, usual for recovery to begin in a few weeks, and in even a 
shorter time should the hemorrhage be unattended by loss of conscious- 
ness. The limb first to recover is the lower extremity. He is able after 
a short time to get out of bed and " hobble" about, or he may retain a 
certain degree of power from the first should the hemorrhage be slight. 
He is subsequently able to raise his hand to his head, and ultimately 
recovers entirely. But this improvement does not always occur, for 
during a cerebritis, which may subsequently take place, a number of seri- 
ous muscular distortions of a permanent character may ensue. A case 
illustrating this is the following : — 

J. C. D., aged 53 ; born in Ireland ; carman. Family history, mother 
died of old age; father died of renal disease. The patient in early life 
was very intemperate, and there are some evidences of syphilitic trouble, 
there being nodes, bald spots, and enlarged glands ; but he denies any 
venereal disease. For three months previous to the attack (it occurred 
three years ago) he suffered from headache, dizziness, and other prodro- 
mal symptoms ; none very marked, however. Fie went to bed one night 
feeling perfectly well, and awoke with " cramps," which affected his right 
leg ; he called his wife, and attempted to get out of bed, when he found he 
was paralyzed. There was no speech trouble whatever. He was placed 
in bed, and remained there for three months, during which time he had 
violent headache in the occipital region. 

Present Condition — Hemiplegia of right side, sensibility slightly im- 
paired, and no atrophy of either the arm or leg. When he stands there is 
slight rigidity of the inner ham-strings. The toes and end of the foot are 
adducted; and when he walks, the foot is raised from the ground about 
one inch ; the knee is rigid, and there is motion only at the hip-joint. The 
lingers of the right hand are in a condition of extreme flexion, and cannot 
be extended by ordinary force ; but. when the hand is placed in hot water 
for some time, the rigidity is partially overcome. The thumb is not in- 
volved; but, when the distal phalanx was extended, it could be bent hack- 
wards some distance, and remained in this condition until it was restored 
by me. The hand is slightly flexed, and the forearm pronated and flexed 
on the arm, and the arm adducted to the body. No lateral movement is 
possible. There was an early history of neuritis, which came on a short 
time after the attack, with decided pain in the shoulder-joint, during which 
the patient applied blisters and mustard poultices. The dynamometer in- 
dicates 20, outer circle, with the right hand, and SO with the left. There 

i- no visible facial paralysis, hut the tongue points slightly to the right 



106 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

side. The surface of the paralyzed side is mottled and cold, and the nails 
arc erenated and horny. 

The facial paralysis is sometimes a grave and permanent condition, and 
is very serious, especially if there be ptosis. Should the paralysis involve 
the muscles of the pharynx, the tongue, or the buccal muscles, the prog- 
nosis is very bad, and these symptoms suggest that the hemorrhage has 
invaded the posterior basal parts of the brain, and, perhaps, the medulla. 
The organs of special sense are affected to a variable extent, and greatly 
modify the prognosis. If there be involvement of the optic disks, retinal 
extravasations, or structural changes of the fundus, a grave character is 
given to the disease ; while such symptoms as ptosis and diplopia, which 
depend upon paralysis of the third and sixth nerve, sometimes disappear 
after a time, though such disappearance may very slowly take place. The 
recurrence of apoplectic attacks is not uncommon, and if there be any spe- 
cial cachexia, they are to be dreaded. Syphilis and gout, as well as renal 
disease, are highly conducive to a return of the trouble ; or advanced age 
is an important predisposing cause of cerebral hemorrhage. When we 
find a calcareous state of the arteries with cerebral hemorrhage, it is very 
probable that other fluxions will follow. I remember a case in which a 
succession of hemorrhages occurred in the person of a middle-aged lady, 
the third of which proved fatal : — 

N. G. A., acred 57. On the evening of February 3, 1873, 1 was called by 
Dr. Win. II. Bennett to see the patient, whom I found in a state of coma. All 
of the characteristic appearances of a profuse cerebral effusion were mani- 
fested. The apoplectic seizure had taken place the day before, and she had 
continued in a comatose state until I saw her with Dr. Bennett. Her surface 
was cool, her breathing slow and stertorous, her pupils dilated, and corneae 
insensitive to the touch; while reflex excitability was entirely abolished, 
so that tickling of the soles was followed by no withdrawal of either limb. 
In this state she remained until the 8th of the monhh, during which time, 
and in fact until the time of her death, in November of the same year, it 
was necessary to draw her water nearly every day. At the end of the 
fifth day there was a slight return of consciousness, but entire inability to 
speak, the patient making a peculiar short sound when she wished to com- 
municate with those about her. There was complete paralysis of the right 
side, but, a faradic current readily produced muscular contractions. From 
this period until September 13th, there was steady improvement, and the 
family, as well as ourselves, were very hopeful. She recovered consider- 
able power over the leg and arm, but was unable to get out of bed, although 
she was Lifted from it and placed in an easy chair, where she remained 
Contented for several hours of the day. She was now able to utter two or 
three words, and seemed to take a Lively interest in all that went on about, 
her. On the L3th of September, while lying in bed, she suddenly became 

comatose, and presented all the symptoms of a fresh hemorrhage. Her 
temperature, which bad before ranged between 98° and 101°, now sank 

to 96 ; and her condition was so critical Unit I remained with her during 

the night of the l ith, when she slightly recovered, regaining her con- 
sciousness "ii the 17lli ; but there was complete loss of power. The tem- 
perature now rose t<» 104 , and she was restless and irritable. Herpower 



CEREBRAL HEMORRHAGE. 107 

of expression had entirely disappeared, and Bhe remained in thi< state 
until the 19th of November, when she died in her last apoplectic attack. 

This patient, before her last illness, had suffered for some time from 
albuminuria, but her symptoms had been almost entirely relieved when 
her first cerebral hemorrhage took place. She was of -pan- build, her 
radial arteries were rigid, and the arcus senilis was visible to a limited 
extent. 

This tendency to cerebral hemorrhage is sometimes seen in gouty sub- 
jects. A patient recently sent to me by Dr. William Lock wood, of Nbr- 
walk, Conn., luul suffered for years from gouty trouble. Besides the pain 
her joints presented gouty swellings, with chalky concretions. AVithin 
the past five years she has suffered from slight hemiplegia of both side- ; 
on the right most severely. In this case it is probable that the rupture of 
a large vessel will some day carry her off. 

Treatment Our treatment must be. first, preventive, second, for 

the attack, and third, for the amelioration of the resulting condition. If 
we have to deal with cachexias of different kinds, appropriate treatment is 
indicated. Should there be gouty trouble, albuminuria, or syphilis, the<e 
are to be met with alkalies (FF. \~). 46), diuretics (FF. 18. 10), and specific 
remedies (F. 2<») such as mercury and the iodides. If there be depraved 
general health, weak heart action, and general debility, we are to support 
our patient by quinine, stimulants, and nourishing food. Combinations 
of digitalis and iron (F. 21) are especially useful when there is low ar- 
terial tension, and rapid heart action. In speaking of cerebral congestion 
I alluded to the conditions which might favor an excessive flow of blood 
to the head, and advocated special forms of treatment. It is not necessary 
to repeat these indications, but I will simply refer to the value of the bro- 
mides given in doses of from 20 to 30 grains three times a day if there be 
any tendency to head fulness, while ergot administered in half-drachm doses 
two or three times during the 24 hours, and the abstraction of blood from 
behind the ears, may be resorted to, should there be a suspicion of imme- 
diate danger. The patient is to be kept perfectly quiet in a cool room, 
cold applications are to be made to the head, and his bowels should be 
emptied by some such cathartics as the compound jalap powder, senna, or 
Rochelle salts. Should we recognize the appearance of any prodromal 
symptoms, we must immediately inform the patient of the dangerous pos- 
sibility, and enjoin upon him the necessity of regulating his mode of lite, 
of breaking off bad habits, and using every means in his power to improve 
cutaneous circulation. The flesh-brush, cold, and sometimes Turkish 
bath-, moderate out-door exercise, and other agents which stimulate the 
surface capillaries ami relieve internal congestion, should be as booh as 
possible resorted to. The patient's diet should be farinaceous, and the 
use of either strong drink or condiments i- to be at once discontinued, lie 
i- to Bleep in a cool room, and on no account wear tight neck gear. The 
feet are to be kept warm, and thick woollen stockings should bo recom- 
mended. Violent exertion, especially forms requiring any fixation of the 



10S DISEASES OF THE CEREBRUM AND CEREBELLUM. 

abdominal muscles or straining, are also to be carefully guarded against. 
Should we be called to find the patient in the actual apoplectic state, 
another line of treatment must be followed out. If in this condition he is 
found lying in a comatose state upon the floor, he is to be lifted gently, 
carried to a bed, and well propped up by pillows so that the head is 
elevated. The room should be kept cool and well ventilated, and cold 
applications are to be applied to his head, while his feet may be kept 
warm by contact with bottles filled with hot water. The room is to be 
darkened, and his collar and shirt collar band should be cut or ripped off, 
bo that the flow of blood to and from the head shall be unembarrassed. It 
i- essential to keep him perfectly quiet ; so loud talking is to be forbidden, 
and officious friends kept away. In times gone by, it was customary always 
to bleed at this stage. I think experience has clearly proven how dan- 
gerous is such practice, for hemorrhage in the brain is very apt to be started 
afresh by any such measure. If, however, the pulse be full, strong, and 
bounding, the patient's face flushed, and his condition one of plethora, the 
abstraction of a few ounces of blood from behind the ears, with cold douches 
to the head and mustard plasters to the calves, will do much good. This 
condition may be so patent to the observer that, perhaps, in rare instances 
and after careful deliberation, he may decide to abstract ten or twelve 
ounces from the arm. If we hear that he has been constipated for several 
days, a drop or two of croton oil or half a grain of elaterium (F. 22) may 
be given in a wafer, or applied to the tongue if he is unable to swallow ; it 
is advisable to give the first remedy, however, if the patient is profoundly 
comatose. Should there be much cardiac excitement, no better medicines 
can be recommended than tincture of veratrum viride (F. 36), or tincture 
of aconite ; the former in doses of from 6 to 8 minims till the pulse force 
is decreased, and the latter in rather large doses, say from 4 to G minims 
:it a time, and after an interval of four hours, another dose, if the pulse 
lias not decreased in volume or frequency. The me'dieal attendant should 
not forget to draw the patient's urine frequently. I have known a neglect 
of this precaution to be followed by pain and distress which the patient in 
hi- helplessness is unable to express ; and I cannot impress too strongly 
upon the student the necessity of remembering this simple procedure. 
When consciousness returns wo may continue tin 1 aconite if it is indicated, 
and perhaps combine it with small doses (say LO grains) of the bromide of 
Bodium (F. 1) every two hours. Active medication of any kind, how- 
ever, IS injudicious in the extreme; so it will not do to give large doses. 
Should there he a condition of prostration, a Jablespoonful or two of milk 
punch may be given every few hours. The subsequent management of 
the case is sufficiently simple; continued quiet, a moderate quantity of 

food easy of digestion, and attention to the functions of the body arc the 

three indications. lie should no! he allowed to gel up to defecate, but 

tie- bed-pan may he placed beneath him. » It may lie found necessary to 

give :m enema, which is better than the administration of purgatives by 

the mouth, and in this Case the patient should not he allowed out of 

bed, even though he may seem bright and sufficiently strong. Cleanliness 



CEREBRAL HEMORRHAGE. 109 

should be insisted upon, and generally necessitates the faithful care of a 
responsible nurse; for, if the patient is not carefully washed, the irritation 
produced by alkaline urine and his loose evacuations may favor the devel- 
opment of bedsores. As a precautionary measure, the buttocks should be 
rubbed with salt and whiskey, or, what is still better, tannin and alcohol. 
Bedsores may occasionally form, and sometimes are unnoticed by the 
physician if he is not on the alert, until his nose or the nurse remind him 
of their existence, the patient either being unconscious of such trouble, or 
unable to inform the physician even if he is aware of their presence. The 
patient should be immediately put on a water bed, and the slough re- 
moved by poultices of flax-seed and charcoal which may be sprinkled with 
iodoform. At the end of the 8th or 9th day, should the tendency be 
to recovery, and the temperature normal, we are left with an ordinary 
case of hemiplegia. What is to be done next? If the attack has been 
a serious one and signalized by marked loss of consciousness, and if 
the secondary rise of temperature be high, it is not best to begin elec- 
trical treatment for fully a month or longer. If the muscles respond 
too quickly to electric stimulus, we are not to use this agent, but to wait 
for some days or weeks, when we may cautiously employ the faradic cur- 
rent to the muscles of the affected side. Large sponge-covered electrodes 
moistened in a salty solution should be employed, so that all the muscles 
may be subjected to the electric stimulus in turn. Electrization may be 
direct or indirect, the muscles being made to contract either when both 
sponges are applied to their bellies, or when one is placed in contact with 
the muscle and the other is applied over the motor nerve by which it is 
supplied. In certain cases faradization fails to do any good whatever, and 
this is especially the case when there is delay in the absorption of the 
clot or any cerebritis. Two cases illustrating the possible advantages of 
this form of treatment are the following : — 

Right Hemiplegia; Cure O. S., aged 52, butler, came under my 

charge October 2d, 1872. He had been deprived of consciousness and 
power of motion a year before by a cerebral hemorrhage, and, after 
resuming the duties of his avocation some months afterwards, continued 
well till three months ago, when a second attack prostrated him; but. 
through the good treatment he received at Bellevue Hospital, he partially 
recovered the power of locomotion. When he came to me for treatment 
there was complete hemiplegia of the left side. There was no peculiarity 
in his gait, beyond a very slight dragging. The arm was slightly atro- 
phied, and the amount of power exerted by a forcible grasp <»t' the dynamo- 
meter was indicated by 15° of the lesser circle. He could not button his 
clothes, nor lift his arm above his head. There was no difficulty in speech, 
except it might be embarrassment in speaking the words containing the 
letters " b" and "p," when the labial muscles were required. 

Electric irritability in the arm was slightly exaggerated. Alter giving 
him a, simple prescription for his constipation, 1 dismissed him. 

In three weeks afterward he returned in very much the same condition. 
I then systematically applied the galvanic current to the head, ami the 

faradic to the limbs. The improvement was marked and immediate. 



110 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

The muscles lost their atrophic state, and became firmer and larger. The 
patient was able to perform many actions with his hands not possible be- 
fore this treatment. Faradization to the lips and cheek has effectually 
overcome the facial paralysis, and he now speaks distinctly. 

Cerebral Softening; Right Hemiplegia; Slight Improvement H. 

Walker, aged 62, Germany, canal-boat captain, presented himself for treat- 
ment in December with a well-marked right hemiplegia. He had been 
injured some time before while on the deck of his canal-boat, and then hit 
upon the head. He was senseless for some days, but recovered, with se- 
vere cerebral disturbance, which, from his wife's statement, must have 
been inflammation of the cerebral substance. 

lie left his bed after some weeks, with persistent pain in the head, 
aphasia, trembling, and a heavy feeling of the lower limbs. His memory 
and other mental faculties became obscured, and there was an uneasy 
expression of the eyes. About a year after the receipt of his original in- 
jury, while working one day in the sun, he had an apoplectic fit. 

After remaining in bed some time, muscular power and cutaneous sen- 
sibility slowly came back. He was able to walk with difficulty; his speech 
was indistinct ; the muscles of both the leg and arm were greatly atrophied ; 
and I determined to use faradism. 

The constant use of the very mild current for several weeks brought 
back, to some degree, the original contour of the paralyzed muscles. He 
Mas able to progress with a cane, but his speech remained imperfect. 
During the treatment he had repeated premonitory signs of a new attack. 
Faradism was resorted to to prevent atrophy, but its good effects were 
only temporary, as there is still softening. 

In connection with this treatment we may give at the same time either 
iodide of potassium, strychnine, or ergot. 

Iodide of Potassium Should there be a syphilitic history, I think we 

may begin at once with this remedy. If there be no such dyscrasia, I do 
not approve of the remedy at any time. It is administered very often 
with the idea of producing absorption of the clot, and is recommended by 
many writers. My limited experience has convinced me that its virtues 
have been very much overestimated. I have found that in many cases 
the patient's tendency to recovery was hastened more by rest, good food, 
and fresh air, than by any other form of medication. It is perhaps of 
value in old cases. 

Phosphorus — Either in its pure state (FF. 2 1, 25, 26), or in combina- 
tion with zinc, it is of great benefit in eases of long standing, especially if 
there be debility and tardy restoration of power in the paralyzed limb. 
The phosphide of zinc ( F. 27) in doses of one-third of a grain, or dilute 
phosphoric acid in half-teaspOOnful doses, are perhaps better borne than 

pure phosphorus. 

Strychnine i> entitled to more consideration. If used al the proper 

time, it i- more powerful to do good than any other remedy I know of, 
perhaps excepting electricity. When the exaggerated electro-muscular 

irritability Bubsides, We may give it iji doses of J., of a grain three 

times b day (F. 29), but before this time its use is attended with 
danger. 



CEREBRAL HEMORRHAGE. 



HI 



Vance 1 has recommended hypodermic injection of strychnine, but I 
ahvavs hesitate when injecting an irritating substance into the belly of a 
paralyzed muscle, for I have repeatedly seen abscesses follow tlie use of 
even a neutral solution properly injected. Impaired muscular vitality and 
tardy reparative nutrition do not favor its use However, Bartholow, 
Eulenberg, and Echeverria recommend its employment, and have had 
good results. Perhaps in paralysis of central origin the trouble to which 
I have alluded is not so much to be feared as when the affection is peri- 
pheral. Each muscle is to be subjected to injection (F. 30), one being bo 
treated each day. Instead of the plan recommended by these authorities, 
viz., injections into the substance of the muscle, I prefer local subcutaneous 
introduction of the solution by the hypodermic syringe. In addition to 
electric treatment, it is well to resort to massage and passive movement of 
the contracted members. The patient may be directed to do this himself, 
and he should be told to rub the paralyzed limb several times daily for at 
least fifteen minutes at a time. Dr. G. M. Beard has recommended heat 
in the treatment of paralysis, and his plan is to place the affected limb in 
a heated earthen drain pipe, well lined with flannel. I can quite agree 
with him, but have found that alternate heat and cold applied to the sur- 
face produce more rapid improvement in nutrition of parts which have lost 
their power. I originally recommended the instrument depicted in Fig 15, 
which will be found a cleanly and convenient apparatus. One receptacle 
is filled with hot water, the other with cold. If the contracted limbs 



Fig. 1, 




Instrumeut for applying Heat and Cold. 

where lately rigidity had taken place are allowed to remain daily for 
fifteen minutes or half an hour in quite hot water, much benefit will 
follow; or, should there be neuritis, we may use blisters, or the actual 
cautery along the course of the nerve trunk. It is of the utmost impor- 
tance that everything should be done to improve the patient's hygienic 
surroundings, diet, and habits. He should not remain in-doors, but stay 
in the open air as much as possible. Food of a nutritious but not o\' a 
tatty character, moderate stimulation if needed, and a course of tonics, 
may constitute our form of treatment during this late stage of' the dis- 
ease. 



Journal of Psychological Medicine. April, ism. 



112 DISEASES OF THE CEREBRUM AND CEREBELLUM. 



CEREBELLAR HEMORRHAGE. 

Very little has been written in regard to effusions of blood into the 
cerebellum, and the diagnosis of such a condition is attended by many 
difficulties. An excellent thesis on the above subject, by Dr. Carion, 1 
contains the following conclusions in regard to diagnosis of this disease: — 

" The predominating symptom of cerebellar hemorrhage is general 
enfeeblement of the muscular system. Hemiplegia is relatively rare ; 
when it exists it is sometimes crossed, sometimes direct. Facial paralysis 
is exceptional; it involves the orbicular muscle of the eyes, and occurs 
on the side of the lesion, and it has for its cause the compression of the 
seventh pair at its point of emergence. The tongue presents a certain 
degree of asthenia, shown by a weakness in its movements, without de- 
viation. Strabismus, like the facial paralysis, is not observed as a symp- 
tom of cerebellar origin ; it may occur from compression of some one of 
the motor nerves of the eye. The conjugated deviation of the eyes has 
been observed ; it always occurs towards the uninjured side as for other 
parts of the encephalic isthmus. The pupils are sometimes dilated — more 
frequently contracted; they sometimes react under the influence of light, 
and are insensible. General sensibility is unaltered even when hemiplegia 
exists; we barely observe a slight anaesthesia in a few rare cases; hyperes- 
thesia is still less frequent. Troubles of special sensibility, principally of 
Bight, have been observed, but they are very rare exceptions. The in- 
telligence is generally preserved in all its integrity. Vomiting is scarcely 
ever absent, and it can rightly be deemed one of the more characteristic 
symptoms of cerebellar hemorrhage." 

1 Abstracted in Chicago Journal of N. Disease, vol. ii. p. 621. 



CEREBRAL AN. EM I A. 113 



CHAPTER III. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (Continued . 

CEREBRAL ANAEMIA. 

Synonyms Syncope, Anemic Cer^brale, Hydrocephaloid. 

Definition A morbid state characterized by an insufficient cerebral 

blood-supply, and expressed by impairment of consciousness, pallor, and 

much muscular enfeeblement. This disease is capable of quite as greal 
modification as cerebral hyperemia, as it may be what only appears to be 
a continued physiological condition, or a grave pathological state. Cere- 
bral anaemia may occur : 1, in an acute form (syncope) ; 2, in a chronic form ; 
3, in an infantile form (the hydrocephaloid of Marshall Hall); and, 4, it is 
localized or partial, as a result of vascular obstruction. The acute form, 
which may be only a simple fainting attack, or the result of shock follow- 
ing severe hemorrhage, is the most familiar variety. It is hardly neces- 
ssary to describe the alarming and familiar condition that we occasionally 
meet with after post-partum hemorrhage, or protracted decubitus, when the 
patient assumes the erect posture. The chronic variety is much less serious 
in its earlier stages, though, when continued, it is often the forerunner of 
certain forms of insanity. It is symptomatized by lowered function of the 
cerebral ganglia, depraved nervous tone, and general intellectual apathy ; 
for, as normal circulation is necessary for the support of healthy brain 
action, and as we find that rapidity of thought and emotional activity are 
proportionate to the increase in the cerebral blood-supply, so must insuffi- 
cient circulation bring with it an impaired state of intellectual functional 
activity. This loss of healthy action may be expressed by drowsiness, 
obscured intelligence, or by irritability and restlessness. 

The infantile form generally follows some of the continued fevers of 
early life, and is a disease of childhood. Occurring during the stage of 
Convalescence of the acute form, it is symptomatized by semi -conscious- 
ness, diarrhoea, great exhaustion, insensitive pupils, pallor, sighing respi- 
ration, and other symptoms. 

The last variety, local or p<irti<tj cerebral anaemia, is that which is 
usually productive of right hemiplegia, and is due, in the majority of 
cases, to thrombosis or embolism, and often has a grave termination. 

It is hardly necessary to allude to Acute Cerebral Anaemia, for it comes 
\\ ithin the province of the surgeon rather than w ithin that of the neurologist. 
Following some grave accident when there i> sudden and excessive loss 

of blood, we will find a. corresponding loss of consciousness, and muscular 
power, sighing, and slow respiration, generally vomiting, and involuntary 

discharge of free- and urine. 
8 



1U 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



The condition is not a Lasting one, and provided the hemorrhage has 
not been too excessive, or the shock too great, there may be a retrograde 
disappearance of the symptoms, and ultimate recovery. 

Symptoms A. In Chronic Cerebral Anaemia Subjective 

Our patient complains of muscular debility, backache, loss of appetite, 
and somnolence, with great despondency, increasing loss of memory, 
marked headache, a regularly distributed cutaneous anaesthesia, some- 
times vomiting, hallucinations of sight and hearing, palpitation, indiges- 
tion, and constipation. Objective — Pallor of the skin, particularly of the 
face, which is of a dirty white color, while the sclerotics are milky blue, 
and the pupils widely dilated. The patient's expression is one of anxiety 
and depression, and if the condition be advanced and of long standing, 
he will spend hours with downcast eyes and a painful hopelessness, and 
hebetude stamped upon every feature. Coldness of the hands, heart- 
murmurs, and a weak, small pulse, are strong evidences of defective 
circulation of this description. The sphygmograph gives an almost 
straight tracing, the pulse-beats being weak and small. I have been 
told very often by these patients that it was with very great difficulty 
that they could refrain from falling asleep in public places, and one 
lady was in the habit of becoming so drowsy in the street car on her 
way to my office that she very often unconsciously passed the street. 
Women who suffer in this way are subject to fainting attacks, which 
occur most often during the menstrual period. Among the most aggra- 
vating symptoms are hallucinations of hearing ; noises — such as ringing of 
bells — are heard; and they occasionally have visual hallucinations in con- 
nection therewith. Delusions are very unusual. Insomnia is some- 
times a distressing symptom, though during the day, as I have before said, 
the patient may have great difficulty in keeping awake. It is not un- 
common for him to complain of a sensation as of falling through the bed ; 
and one of the prominent elements of his sleeplessness is the continuous 
roaring in his ears, which is sometimes compared to the sounds heard 
when a shell or other hollow body is placed over the ear. If the 
condition lias gone on to the state where mental impairment has begun. 
we will generally find that there is venous stasis, and that the back of 
the hands is of a livid color, while pressure leaves a white mark which 
slowly disappears. The lips are pale, thick, and pulled, and the line 

between the mucous membrane and skin is less sharply defined than in 
the normal state. The urine is passed in large quantities, is colorless 

ami limpid, ami of a low specific gra\iiv. The heart-sounds are weak, 

and it i'8 not uncommon to find an aortic bellows murmur. There may be 
amaurosis, and other defects of vision. Digestive derangements are quite 

common, and vomiting, which is cerebral, is in some cases frequent and 
obstinate The individuals presenting these symptoms are poorly 

nourished. There may be oedema of the legs and ankles, ami sometimes 

albuminuria. Feebleness and muscular^anl of power, of a light grade, 



C E B E B R A L A N .K.MIA. II 5 

are often expressed ; and the comfort of a sofa or easy chair i- sought by 
the patient, who seems disinclined to take any exertion whatever. 

B. In Infantile Cerebral Ax.emia. — Marshall Hall has called atten- 
tion to a most interesting form of anaemia, to which I have casually referred, 
and to which lie ha- given the name " Hydrocephaloid." The die 
depends principally upon exudation, and has its origin in early infancy. 
A case i- related by Hall : — 

"The patient, a boy, aged four, became comatose and perfectly blind 
and deaf. The ringer might approach the half-closed eye without induc- 
ing any movement, but the moment it touched the eyelash, the eyelid- 
would close. A spoon applied to the lips excited their action, and the 
food it contained was carried into the pharynx and -wallowed ; tin- respi- 
ration was frequently suspended; a sigh, and frequent respiration fol- 
lowed. The cerebral functions had ceased; the true spinal function- were 
made." 1 

Marshall Hall lays down certain rules from which I may extract the fol- 
lowing. We should especially be upon our guard not to mistake the stupor 
or coma into which the state of irritability is apt to subside, for natural 
Bleep, and for an indication of returning health. " The pallor and cold- 
ness of the cheeks, the half-closed eyelid, and the irregular breathing, will 
sufficiently distinguish the two cases." He divides the affection into two 
Btages, the first of which is one of irritability, the second, of coma. In the 
former there is some attempt at reaction, and in both stages there is 
some resemblance to acute hydrocephalus. 

" In the first stage the infant becomes irritable, restless, and feverish ; 
the face is flushed, the surface hot, and the pulse frequent ; there is an 
undue sensitiveness of the nerves of feeling, and the little patient starts 
on being touched, or from any sudden noise ; there is sighing, and moan- 
ing during sleep, and screaming ; the bowels are flatulent and loose, and 
the evacuations are mucous and disordered. If through an erroneous 
notion of this affection nourishment and cordials be not given, or if the 
diarrhoea continue either spontaneously or from the administration of medi- 
cine, the exhaustion which ensues is very apt to lead to a very different 
train of symptoms. The countenance becomes pale, the cheek- cool or 
cold ; the eyelids are half closed, the eyes are unfixed and unattracted by 
any object placed before them ; the pupils are unmoved on the approach 
of light ; the breathing, from being quick, becomes irregular, and affected 
by Blghs ; the voice becomes husky, and there is sometime- a husky tea/- 
ing cough ; and evidently, if the strength of the little patient continues to 
decline, there is crepitus or rattling in the breathing; the evacuations arc 
usually green : the feel are apt to be cold." 

1 1 is my opinion that this form of disease is very much more common 
than it is supposed to be, and that many deaths usually reported a- mara-- 
mns are evidently of this nature. 

Of local cerebral ancemia I will speak in another chapter. 



1 Op. tit., p. 1S1 



Ill, 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



Causes As causes of cerebral anaemia we may roughly class all 

agents that interfere -with the cerebral blood-supply, and consider them as 
remote or local. Whether the fault lies in a diseased heart, which is 
unable to supply the brain with its normal amount of blood, or whether 
there is some mechanical obstruction through pressure upon the cerebral 
arteries, the morbid condition is the same. By far the most common cause 
of this cerebral condition is a general anaemia which may be dependent 
upon a number of conditions which drain the vessels. Among these may 
be ('numerated uterine hemorrhages of various kinds, hemorrhoidal fluxes, 
cancers and other diseases attended by hemorrhage, as well as general dis- 
eases of assimilation which prevent the proper enrichment of the blood. 
A very -light reduction in the quantity of the blood will be followed 
usually by indications of the want Pelt by regions deprived of their nourish- 
ment ; but when the nervous system sutlers this deprivation, the loss is 
immediately shown. Haller has calculated that one-fifth of all the blood 
in the body is sent to the brain, and with this fact in view, it will not be 
difficult to realize how any modification of circulation will result in im- 
mediate changes. Heart disease generally in the form of fatty enlarge- 
ment, when there is mitral stenosis, or when functional activity is interfered 
with by emotional or other causes, may have much to do with cerebral 
anaemia. This cause enters, perhaps, more extensively into the production 
of chronic cerebral anaemia than any other. Owing to the delicate arrange- 
ment of the vaso-motor nerves which so beautifully control the supply of 
cerebral blood, when through emotional or other causes the function is altered, 
there will be immediate intra- as well as extra-cranial anaemia. We have 
all seen that sudden emotions not only blanch the face, but as well product' 
faintness. Various modifications of the functions of the liver may be as- 
sociated with states of cerebral anaemia through modification of function 
of this system of nerves. Milner Fothergill has pointed out the association 
between the nei \ es of this organ and those which supply the vertebral arte- 
ries : and Schroeder Van der Kolk and Laycock have said that those parts 
of the brain supplied by the vertebral arteries were the seat of the emo- 
tion-. Fothergill reminds us of the fact that we may have functional de- 
rangement of the live]- w ithout affection of the intellect, but with depressed 
emotional states. 'There are other forms of abdominal trouble, such as an 

overloaded rectum and uterine derangement, which coexist with melancholia 
and depression of spirits, and every practitioner has seen the wonderful 
elation of spirits which follows a free movement of the bowels after con- 
tinued torpidity of tie liver. The extension of the cerebral vaso-motor 

and the involvement of other areas of blood-supply may. of course, make 

the condition a more extensive one. and disturbances of motility and in- 
tellection naturally ensue. 

Pressure made upon the carotid or vertebral arteries by various tumors 
or growth-, or sometimes by aneurisms, i> a mechanical cause of cerebral 
anaemia of decided importance. I assisted :it an operation several years 
ago where the carotid on one side was tied by Drs. Sands and Parker, of 

this city. In less than I wenly-four hours the patient died from extensive 



CEREBRAL ANAEMIA. 117 

anaemia. Embolism is perhaps the simplest example of a cause of this 
kind. A detached vegetation or clol is washed into the circulation, up 
through the left carotid and into the middle cerebral artery lor instance, 
cutting off the circulation, and producing extensive cerebral anaemia on the 
left side, while right hemiplegia and aphasia follow. In thrombosis the 
artery is narrowed by the gradual deposit of plastic substance until finally 
it- calibre is occluded, and the blood must take some other channel or not 
reach the part which it normally supplied. 

Apoplexy, or brain tumors of various kinds, and atheromatous narrowing 
of cerebral arteries, are also direct causes. In the first two instances pres- 
sure is made directly upon the brain substance, and in the latter there is 
a gradual change in the vessels themselves. 

As a familiar illustration of how cerebral anaemia may be produced by 
a drain upon the general vascular system, I may allude to the case of a 
patient whose trouble dated from a series of miscarriages occurring within 
a very short period. One of these happened when it was impossible to 
procure medical attendance, and she lost a great quantity of blood. 

After the last event she never completely recovered, and her present 
disagreeable and annoying condition remained. She was drowsy, had 
frontal headache, ringing in the ears ; was constipated, etc. Another pa- 
tient was subject to attacks of despondency, when life seemed very dis- 
tasteful and gloomy. Her appearance was characteristic. White skin, cold 
hands, palpitation, and other symptoms enabled me to diagnose cerebral 
anaemia, and vomiting and vertigo were confirmatory symptoms. The cause 
was found to arise from very troublesome hemorrhoids. After cauteriza- 
tion and removal, she regained her previous health. 

Certain medicinal agents, as well as tobacco, produce cerebral anaemia. 
The bromides undoubtedly possess this property, while chloral and chlo- 
roform, if taken for a long time, as they often are, are likely to provoke 
an anaemic state of the brain which is distressing in the extreme. 1 
can recall the case of a young lady who confessed that she had been 
in the habit of putting herself to sleep at night with chloroform, besides 
inhaling it several times during the day. I have never seen such a 
typical case of this morbid condition. Her skin Avas of a hue of waxy 
whiteness, her pulse small and fluttering, her pupils widely dilated, and 
her languor and muscular feebleness very profound. Depression and the 
contemplation of suicide prompted her to confess her bad habit. Tobacco, 
though only affecting the heart through its interference with pulmonary 
functions, undoubtedly produces in some individuals a condition of cerebral 
anaemia. The clammy, white skin, giddiness, dilated pupils, hurried 
respiration, ami unsteady, weak pulse, and not uncommonly syncope, are, 
I think, evidences of cerebral anaemia. Certainly the after effects are 
(dearly suggestive of this morbid cerebral condition. That tobacco, in 
many individuals, in fact the great proportion, possesses stimulating 
effects, there can be no doubt ; but the variation of effects which follow 
the administration of opium, for example, when there i> Borne idiosyn- 
crasy, clearly leads us to infer that its action is sometimes different from 



118 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

that determined by the majority of physiologists. Physostigma, aconite, 
and other cardiac sedatives may he mentioned as other anaemiants. 

Various conditions, when the blood is poisoned, such as lithiasis, are 
sometimes unsuspected, but nevertheless very important causes of cerebral 
anaemia. 

Morbid Anatomy and Pathology — As we might expect, the 
anaemic brain is white, firm, reduced in bulk, and greatly changed. The 
vessels are empty, and there are no pnncta visible when a cut is made 
through the white matter. We may find a distension of the perivascular 
spaces by fluids, and occasionally some thickening of the neuroglia. 

I have spoken in another chapter of the circumstances which modify 
the cerebral circulation. It only remains for me to refer to the experi- 
ment- of Kausmall and Tenner, Burrowes, and others, who have devoted a 
great deal of attention to the experimental study of this subject. The ex- 
periments of the first two observers were made upon six adults and a number 
of rabbit.-. When the carotids of the human subject were compressed, pallor, 
loss of consciousness, slow respiration, and dilated pupils were produced, 
which disappeared when the pressure was remitted, and could again be 
produced at will. Tying of the carotids was followed by convulsions, un- 
consciousness, and death, when jiost-mortem examination revealed evi- 
dences of softening. 

In the first experiments, when pressure was remitted, there were evi- 
dences of a secondary cerebral hyperaemia with flushing of the face. Ob- 
struction of the artery on one side may produce loss of motor power on 
the other, with immediate giddiness, loss of consciousness, syncope, and 
occasionally vomiting. There may be complete recovery after such an 
accident, but " it is always imperfect when the obstruction is situated on 
the further side (from the heart) of the circle of AVillis." 1 The obstruc- 
tion of the minor cerebral arteries is followed by less complete 1 intellectual 
derangement, by more marked vomiting and giddiness. Should the anae- 
mia be quickly produced, as it is when severe injuries have been received 
and the patient literally '"bleeds to death," convulsions form a prominent 
and almost constant symptom. Sighing respiration, and the other phe- 
nomena I have already named, are also expressed. 

In cerebral anaemia there is impairment of functional activity, while in 
congestion the reverse is the pule. Post-mortem examination shows that 
the brain in cerebral anaemia is white, condensed, and less bulky, and 

t he \ essels are empty. 

We have already cited the causes of cerebral anaemia, and it now re- 
mains for us to consider the part they play. Cerebral anaemia depends 

upon — 

1. The insufficiency of cerebral blood-supply through actual deficiency. 
'1. The action of certain agents upon the nerve-filaments themselves. 
It i> hardly necessary to again more than allude to the first of these. 
In this condition the effect of posture is said to greatly influence the cere- 



1 II. .Jones, Functional NervouasDisorders, p. <;<;. 



CEREBRAL AN.KMIA. 119 

bra! state. The erect position is conducive to an aggravation of the 
symptoms, while recumbency favors the flow of blood to the brain. This 
relief follows the supine position when the individual has an ordinary 
attack of syncope. Abercrombie relates a case which is quoted by Foth- 
ergill, and which is, I think, a beautiful practical example of this change. 
The patient, who was greatly reduced by some gastric disease, gradually 
became deaf, but heard perfectly well when he lay down or stooped forward. 
As soon as his face became flushed, the improvement iii hearing began, and 
when he raised his head the blush faded away, and he relapsed into hi- old 
condition. Abdominal paracentesis is followed bysyncope, if the patient is 
not made to assume the supine position, for during ascites the abdominal 
veins are so impinged upon that when pressure is remitted they are capa- 
ble of receiving a very large quantity of blood — in fact, so much as to 
deprive the brain, and produce the anaemia. A quantity of blood gravi- 
tates directly through the superior and inferior venae cava-, not being 
thrown over by the right ventricle, but passing down into the abdominal 
vessels. 

Insufficiency of cerebral blood may be due to a powerless heart, that 
organ being unable to lift a, requisite amount of blood for the nutrition 
of the brain. Not only may this be a direct result of a. weakened organ, 
but it may follow strong emotional excitement. 

This assumption of the recumbent posture is one of the best thera- 
peutical means in certain cases. Dr. Weir Mitchell has had extraordinary 
success in the management of certain intractable cases, some of which 
were directly dependent upon cerebral anaemia. 

Of the second mode of production, I may allude to the local effect of 
some blood poisons, and the influence of the emotions. Bearing in mind 
the important physiological law that section of the sympathetic is followed 
by vascular dilatation, and that irritation of the proximal end produces 
contraction, we are enabled to realize many of the pathological process 9 
which occur in the production of cerebral anaemia. Anteriorly the vaso- 
motor fibres are derived from the superior cervical ganglion, and poste- 
riorly the fibres come from the inferior cervical ganglion. These fila- 
ments follow the course of the large cerebral vessels, and in this manner 
supply every part of the cerebral mass. 

This close relation with the vascular system explains the prompt action 
upon the heart of certain exciting emotions, and secondarily tin 1 variation in 
blood-supply. This is the idea held by Fothergill and others, and most ad- 
mirably explained by that writer in an article in the \\'<sf Riding Reports, 1 

The connection between variation in cell action and the function of 
the sympathetic fibres is. perhaps, the most interesting part of the subject. 
Primarily the influence of impoverished blood affects the integrity of the 
cerebral nerve-cells, and secondarily the influence of the cerebrospinal 
fibres is suspended. 1 have no doubt that a. certain train of Bymptoms, 
which is sometimes expressed during general anaemia, is the result of a 

1 Art. Cereb. Anaemia, vol. iv. p. 108. 



120 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

temporary local hyperaemia, through paresis of the vaso-motor fibres; and 
that [tarts of the brain are congested while others are anaemic. 

A result of continued emptiness of the vessels is an cedematous condition 
of the brain, from distension of the perivascular spaces by the cerebro- 
spinal fluid. This condition is sometimes so extensive as to receive the 
name " serous apoplexy," and profound stupor is the result. 

In relation to sleep and its connection with cerebral anaemia, it will be 
well to say a few words. A great many observers, among whom were 
Durham, Kau small, Tenner, and Fleming, strongly held that the brain 
was anaemic during repose, the anaemia being the cause of sleep. Others 
have differed with them; but experimental facts seem to favor this view of 
the case. Not only may anaemia be unattended by sleep, but a condition 
of unconsciousness closely resembling healthy sleep may be the result of 
a hyperaemic cerebral state. Opium, alcohol, and various agents which 
increase the cerebral blood-supply, act in this way ; but the stupor which 
follows a toxic dose of either agent must not be confounded with natural 
sleep. Certain curious facts militate strongly against the anaemic idea, 
or, at least, against the assertion that sleep is directly dependent upon a 
diminution in the supply of blood to the brain. 

1. There are many anaemic individuals who sleep only after taking 
stimulants. I think all who have seen the good effects of a bottle of ale 
at bedtime will be disposed to take this view. The sleep produced in 
no way resembles stupor, and there is no disagreeable sense of fatigue in 
t he morning. 

2. My friend, Dr. Janeway, has called my attention to an experiment 
he has made. This consists in the administration of a few drops of nitrite 
of amyl to a sleeping person. Although cerebral congestion follows, the 
patient does not awake. 

3. If mental action is dependent upon activity of the cerebral circula- 
tion, and sleep upon anaemia, it almost seems that dreams must be incon- 
sistent with sleep; while, on the contrary, many individuals enjoy the most 
vivid and constant dreams, jiiid do not awake till their usual hour. 

I ;un more inclined to think that the production of sleep depends upon 
some change in the function of the nerve-cell, and that this modified form 
of action is not necessarily dependent upon either anaemia or congestion in 
;in\ particular case, but that, if there be ancemia, it is secondary to the cell- 
change, whatever that may be. 

The connection of a torpid condition of the liver with cerebral anaemia 
will explain the constipation, which is anything but an uncommon accom- 
paniment <>f the disease. Intestinal accumulation, as Fothergill says, 
may "stand to cerebral anaemia in a. causal as well as a consequential re- 
lationship," and h<- alludes to the experiments of Ludwig and Daziel to 
illustrate the connection. A finger passed over the intestines produced 
acceleration of the intracranial circulation. 

The general Bymptoms, such as languor, the various modifications of 
sensation, etc., are directly due to a, diminution in nervous supply. 

Diagnosis.— Acute general attacks yf cerebral anaemia may be con- 



CEREBRAL ANyEMiA. 121 

founded with cerebral congestion, Btomachic and auditory vertigo. I have 
already spoken of the distinction to be made between the disease under 
discussion and cerebral hyperemia, and it is not necessary to say more. 
Attacks of .stomachic vertigo, or Meniere's disease, are symptomatized 
as follows : The first is characterized by a feeling of "emptiness of the 
head," reeling and swimming, general coldness; "objects whirl around ;" 
no loss of consciousness, nor marked disposition to sleep. No dependence 
upon a very full or empty stomach, and the possible existence of gastral- 
gia. In Meniere's disease there is aural disease, and turning or whirling 
generally to one side, from left to right, and the condition is not continu- 
ous. The most important facts to discover are in relation to tin- cause, 
whether it be a secondary condition, the result of cardiac trouble, or 
whether it be simply a result of general anaemia, without any organic 
disease. 

Chronic cerebral anaemia presents various phases, and it is almost 
impossible to go over the long list of general diseases which, like hysteria. 
it may counterfeit. 

Prognosis As cerebral anaemia is nearly always due to some cause 

which is easy of removal, the prognosis is good. If, however, there be 
organic heart trouble, the case assumes a different aspect. Old cases are 
extremely discouraging, particularly when the patients happen to be women. 
Irritability and hysteria generally enter largely into the complaint, and 
treatment is sometimes almost useless. If uterine, hemorrhoidal fluxes, 
and other such drains exist, of course their amelioration is attended by 
cure. Should the loss of blood be caused by a cancerous uterus or rectum. 
the prognosis is consequently very bad. 

Treatment It is of the utmost importance that the practitioner 

should seek out and remove, if possible, such conditions as diminish the 
amount of blood in the body, and consequently he must ascertain the exist- 
ence of hemorrhoids, uterine hemorrhages, either periodical or irregular, 
and apply appropriate remedies in such cases. Without venturing upon 
another field, I would call attention to the necessity, in Cases where there 
is monorrhagia, of overcoming this condition as promptly as possible, for 
Special treatment of the nervous condition is of little avail when the 
woman every month loses a quantity of blood largely in excess of what is 
made in the interim. 

Active measures are necessary when there is general anaemia, and tor 
this purpose we must resort to iron, strychnia, phosphorus in some of its 
forms, cod-liver oil, an abundance of nutritious food, with Stimulants Such 
as milk punches, porter, or ale (FF. 8, '.». 1<». 2 1. 29). 

A word o]- two is necessary in regard to the diet, and the quantity of alco- 
hol given to these patients. It is the physician's bad fortune to meet with 
Cases of this kind in which digestive troubles are dependent entirely upon an 

enfeebled state of the viscera, ami we should therefore use great care and 

not be impatient. A hearty regimen, and too much alcohol, may do mischief 
instead of good. It is well, therefore, in certain cases, to give the stomach 
as little work as possible, and at the same time to allow it to exert itself 



122 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



iii a way that will most benefit its possessor. A very little food, given at 
short intervals, \\ ill be more perfectly digested and assimilated than a 
lame quantity taken at long intervals. I have often given a few table- 
spoonfuls of cream or beef-juice every hour for days, and have ultimately seen 
such a marked improvement and an increased capacity for work upon the 
pari of the digestive organs, that the more gross varieties of animal food, 
as well as alcohol, were after a while borne in large quantities. Should 
this enfeeblement of the digestive organs exist, we may give either pan- 
creatine emulsion, or strychnia and muriatic acid (FF. 31, 33, 34). Ex- 
trael of malt is sometimes very well borne, and hastens the improvement. 
This may he given in combination with cod-liver oil (F. 32). 

One of the most useful forms of treatment to which I have already 
alluded — the " rest treatment" of Weir Mitchell — is of marked service 
in old cases, especially if the subjects happen to be women. Dr. Mit- 
chell has treated many cases which are almost identical with those that 
generally come under the head of chronic cerebral anaemia. He says : 
" These cases vary, of course, endlessly ; but their essence is a state of 
reduced nutrition, which no mere tonic will cure, while they are afoot and 
living on their capital. The main symptoms are the state of painful tire, 
the low temperature, the great or less anaemia, the quick pulse, the excess 
of white blood." He calls attention to the necessity for perfect quiet, and 
at the same time daily massage and faradization of all the muscles. His 
treatment is expressed in his own words thus : " The amount of feeding, 
of massage, and of faradic-muscle exercise which each case will bear and 
prosper under, is a matter to be told early in the case by watching the 
pulse, I lie temperature, and the appetite. In these cases the pulse is 
always rapid. If it fall, if the temperature rise, above all, if there be the 
least gain in flesh, I know that I am on the right path, and am not moving 
on it too fast ; but if these symptoms be reversed, and if the patient censes 
to be hopeful and looks weary, then 1 lessen the passive exercise, and wait 
a little ; but, above all, I listen to what my masseur or masseuse tells me 
of the ease with which the limbs flush or the readiness with which the 
muscles grow linn under the kneading lingers, for in this matter I get to 
have a very shrewd judgment. As to the rectal feeding, which I rarely 
omit. I say little, as it is well understood. It should always include cod- 
liver oil. There is only this to be borne in mind: most medical men feed 
by the bowel when they cannot by the mouth. I like to use both ends at 
once." 

Thifl treatment seems to be the very best in cases of long standing; but 
it i- well to Bee first what fresh air, Ionics, and abundant nitrogenous food 

will do for our patient, while >he pursues her ordinary life. 

I have lately modified Mitchell's treatment, and have placed my patient 
in ,i darkened room. This condition, which is attended by excitement 
and irritability of the organs of special sense, is much benefited by abso- 
lute quiet, and, therefore, darkness and r<Vt are mosi agreeable and useful 
forms ot treatment. ^ 



STOMACHIC VERTIGO. 123 



STOMACHIC VERTIGO. 

Synonyms. — Vertigo a stomacho laeso (Lat.) ; Vertige stomacal ( Fr.) ; 
Gastric vertigo. 

Definition A condition of giddiness, hallucination, nausea, head- 
ache, etc., without loss of consciousness, and probably dependent upon a 
reflex excitation of the cerebral vessels from some visceral irritation. 

Symptoms. — The condition, which is a very common one is pro- 
duced, in most cases, directly after a hearty meal, or else when the 
stomach is entirely empty. A sense of gastric fulness at first, while head- 
ache, with buzzing in the ears, palpitation, and giddiness of a few mo- 
ments' duration, follow. Should there be hallucinations, the patient is 
not worried by them, but realizes their unsubstantial character. Trous- 
seau 1 insists upon the fact that the hallucinations of this condition differ 
from those attendant upon cerebral hyperaemia from the fact that in this 
form they do not occur when the head is lowered, which is the case in 
cerebral hyperaemia. 

Causation Stomachic vertigo is more a condition of middle life and 

old age than one of youth. Young women occasionally suffer, but this is 
the exception. Certain forms of indigestible food may directly provoke 
the attack, or it may follow violent exercise after a hastily eaten meal. 
In one case of which I know, a gentleman ran for over a mile to catch a 
morning train. He had arisen but a few moments before, and had hurri- 
edly eaten his breakfast. He fell to the ground, but did not lose con- 
sciousness. The disorder often occurs when the individual has been eating 
irregularly; and business men or others who take but little exercise and 
eat hurriedly are very often the sufferers. Handfield Jones 2 considers taenia 
to be a frequent cause of vertigo, and such has been my own experience. 

Treatment Trousseau, who has written most fully upon the sub- 
ject, recommends that the patient be directed to drink every morning a 
glassful of (piassia infusion made by maceration of the shavings in wat< r, 
or to use the goblet of quassia wood in which the water is allowed to re- 
main until it has become bitter. After each meal one of these powders 
should be taken : — 

R. Soda? bicarb., 

Magnesias calc, :1a gr. w. 
Cretae praep. gss.— M. 
Divid. in chart, no. iij. — Sig. One after each meal. 

Strychnia, pepsine, and sometimes bismuth (FF. 30,31, 28) are excel- 
lent remedies, and should be given, while attention i- to be paid to the 
patient's general habits. 

1 Clinical Medicine, Am. edition, vol. ii. p. 

2 Functional Nervous Disorders, n. tit. 



124 



DISEASES OF THE CEREBRUM AND CEREBELLUM, 



AUDITORY VERTIGO. 

Synonyms Labyrinthine vertigo ; Meniere's disease. 

Definition — A morbid cerebral condition expressed by vertigo and 
rotatory movements, unattended by loss of consciousness, and dependent 
upon disease of the labyrinth, or other parts of the central auditory appa- 
ratus. 

To Meniere 1 belongs the credit of having first accurately described this 
disease, though Triquet 2 gives the credit of its discovery to Saissy, of 
Lyons, who observed a nervous condition connected with diseases of the 
inner ear. Trousseau 3 says that Saissy did not mention vertigo as a 
symptom of the condition to which he called attention. It is enough to 
Bay that, prior to 1861, the form then known only as stomachic vertigo 
was always supposed to arise from digestive troubles, and the existence of 
a distinct variety, with aural disease, was not appreciated. 

Symptoms — Generally there are some indications of otitis, whether 
they be simple inflammation denoted by pain, or a discharge of bloody 
pus, or even perforation of the tympanum. In many cases the disease 
may be preceded by a chill, and this should be always looked upon as a 
serious indication. The patient is suddenly seized with vertigo, and at 
the same time experiences a feeding of nausea and buzzing in the ears, 
which may be double, or confined to one side. This vertiginous condi- 
tion calls to mind a sensation experienced when one is twirled in a swing. 
A boyish prank is to twist the ropes of a swing while the unhappy victim 
is seated therein; then to suddenly release the board, which revolves with 
great rapidity as the ropes unwind. This description of the symptom was 
given me by a, patient who suffered from nausea at the same time with 
vertigo. The vertigo is attended by a loss of equilibrium. The patient 
sways or reels, and there is an impulse to turn from the left to right when 
the left ear is affected, and vice versa when the oHier is the seat of the 
disease. Ferrier 4 describes a sensation usually experienced. lie (the 
patient) feels " as if he were suddenly lifted from the ground and pitched 
forward and to the right side." There is also a tendency, when walking, 
to keep (dose to the side of the Avail or house which corresponds to the 

affected ear. Deafness is generally present, but this is, of course, the 
result of the destructive aural disease. 6 Recovery is not always to be 



1 Bulletin de l'Acade'mie de M6d., sexvi. p. 241. 

2 Lecons cliniques but les Maladies de 1' Oreille, p. 118, Paris 1868. 
:! Loc. cit., p. 868. 

1 Labyrinthine Vertigo, \Y. K. Reports, vol. \. p. 84. 

• Irum-Brown is of the opinion that, in addition to the other sen<cs. (he indi- 
vidual possesses one of rotation, !>\ which we arc able to determine the axis 
about which rotation of the head takes place; the direction of rotation, and its 
rate, [n explaining some experiments perftfwned by him. he says: "Inordi- 
nary circumstances we do not wholh depend n|4,r>n t his sense for such in fori nation. 

Sight, bearing, touch, and muscular sense assist us in determining the direction 



AUDITORY VERTIGO. 125 

expected, but a great many cases improve under appropriate treatment 
presently to be described. 

John B., aged 47, iron railing manufacturer. Nearly eighteen months 
ago, lie became troubled by noises in i he lefl ear, which he compared to 
the "singing of canary birds," and afterwards this Bubjective noise 
changed its character, and he described it as a continuous roaring like the 
escape of steam from ;i boiler. To this sound he lias since become par- 
tially accustomed. He has never had earache, hut nine years ago there whs 
a discharge from the left ear, but there have since been no other symp- 
toms, lie has suffered for a long time from post-pharyngeal catarrh, and 
there is now a catarrh of both Eustachian tubes. When a young man he 
had secondary syphilitic symptoms, but denies having had any primary 
sore. Sixteen months ago, during hot weather, lie was seized in the street 
with dizziness and reeling, and was obliged to grasp a lamp-post for sup- 
port.. There was no loss of consciousness, and lie realized fully his con- 
dition of helplessness. lie said that he felt as if he was being " twirled" 
from right to left, but did not fall. This attack occurred before dinner 
(about 11 A. M.), and his stomach was neither filled nor completely 
empty, for he had eaten his breakfast at 8 A. 31. lie was perfectly well 
otherwise, and the only disordered function was that of the lower bowels, 
for he was constipated. He has had these attacks very frequently. For 
the six months following the first attack of vertigo they occurred about 
once a month, but since then they had been of daily recurrence. 

Present State The patient's digestive organs an 1 in good condition. 

and his appetite is fair. He is ordinarily of constipated habit, but it re- 
quires but slight medication to overcome this, lie is of medium height, 
weighs 143 pounds, and seems a well-nourished man. II is face is some- 
what suffused when he becomes excited, but he is ordinarily pale. His 
eyes convey an anxious expression, but the pupils are normal. His hair 
is scanty and gray, but not removed in patches, nor suggestive of any pre- 
vious syphilitic trouble. He has occasional headache, and still complains 
of the "roaring" noise on the left side. Hears the tick of a watch only 
six inches from left ear, and indistinctly at any distance within this 
limit. Watch tick heard at five inches from right ear, but more perfectly. 
Dr. C. S. Bull examined his eyes, and the following is his report : — 



and amount of our motions of rotation, as well as of those of translation; but if 
we purposely deprive ourselves of such aid, we find that we can still determine 
with considerable accuracy the axis, the direction, and the rate of rotation. The 
experiments that I have made with the view of determining this point were con- 
ducted as follows: A stool was placed on the centre of a table capable of rotating 
smoothly about a vertical axis : upon this the experimenter sat, his eyes being 
closed and bandaged : an assistant; then turned the table as smoothly as possible 
through an angle of the sense and extent of which the experimenter had net been 
informed. It was found that, with moderate speed, and when net more than 
one or two complete turns were made at once, the experimenter could form a 

tolerably accurate judgment of the angle through which he had been turned. 
By placing the head in various positions, it was possible to make tin- vertical 
axis coincide with any straight line in the head. It was found that the accuracy 
of the sense was not the same for each position of the axis in the head; and. fur- 
ther, that the minimum perceptible angular rate of rotation varied also with the 
position of the axis. It was also found that considerable differences of accuracy 
exist in different individuals." 



12G 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



II 



Examination of J. B 

1 



30 



40+ 

Fundus perfectly normal." 



20 . 20 

: with convex 32 spherical V= ^A , 



His attacks occur nearly every day, and seem to have no relation with 
the condition of digestion. These " reeling tits " may take place at any 
time of the day. last for five or six minutes, and usually are not so 
sudden as to prevent him from taking hold of the nearest lamp-post or 
railing. Jn a recent vertiginous seizure he was taken just as he was 
about Jo get into a street car, and would have fallen had the conductor 
not dragged him upon the step. He tells me that he has asked his wife 
to " turn him the other way " when the attack occurs, and usually this has 
the effect of abating it. I placed him upon large doses of quinine at first, 
which have decidedly influenced the frequency and character of the ver- 
tigo, so that he often passes a week at a time without any seizure. Bro- 
mide of potassium had been prescribed for him before his visit by another 
physician, but he tells me that this drug increased the dizziness. The 
phenomena of these attacks are the following: He suddenly feels light 
headache ; objects swim about him from right to left while he seems 
to be rotated the other way, and during this period he separates his feet 
and braces himself. The outlines of the houses, trees, and sidewalks are 
blurred and distorted, and after a few minutes they suddenly assume their 
proper relations, and the attack passes off, and he has subsequent 
headache. 

Causes The disease being directly due to aural inflammation, and 

the causes of this condition, whether they be exposure, the extension of 
other inflammatory processes, or the injudicious use of douches and injec- 
tion, are only secondarily productive of the neurosis. 

Pathology The experiments of Flourens and (Jolt/. 1 have been the 

basis lor our pathological study of Meniere's disease. Brown-Se'quard 8 
and Flourens demonstrated that when the membranous canals of the 
labyrinth were divided, various disturbances of equilibrium followed. 
Walter and Lincke 3 and others have divided the horizontal canals and 
produced oscillation of the eyeballs, swaying of the head from one side to 
the other; and have seen the animal spin round like a top. Division of 
the posterior vertical canal causes the animal to topple over backwards, 
an. I the head is moved backwards and forwards. When tin 1 superior ver- 
tical canals were cut across, the animal pitched forward. It may be seen 
that a diseased condition, not Limited to any particular spot, may produce 
.1 combination of these symptoms. 

Brown-S6quard, in speaking of the relation of rotatory movements to 
auditory irritation, calls attention to these familiar illustrations: — 

" 1st. Anv one who has received an injection of cold water in the ear 



1 Pfluger'e Archn fttr Physiologic, L870, and Rechexches sur lea Propr. et Lei 
I onctioiu du Systeme Nerveux, 2d ed. 
■ Central Nervouf System, Philadelphia, is?;o, and Experimental Researches, 

1 Wagner*! Handworterbuch der Physiol., vol. vi., is.">:i. p. 420etseq. 



AUDITORY VERTIGO. 127 

may know that it produces a kind of vertigo, and that it is difficult to walk 
straight for some time after this irritation. 2d. A sudden noise make- the 
whole body jump, particularly in old people, or in persons attacked with 
anaemia, chlorosis, epilepsy, chorea, hysteria, hydrophobia, and in certain 
cases of poisoning; in a word, in all circumstances in which the control of 
the will over reflex actions is lost or diminished. 3d. Vertigo and various 
convulsive movements in cases of irritation of the acoustic nerve have 
been observed in adults and children. Rotatory movements have taken 
place in cases of suppurative inflammation of the ear, and twice imme- 
diately after an injection of nitrate of silver." Ferrier, 1 who has written 
most clearly upon this disease, goes very deeply into the subject. In the 
normal state it is necessary for tactile, visual, and auditory impressions to 
be unembarrassed, so that the power of equilibriation may be preserved ; 
but it is of absolute importance that the labyrinthine functions should be 
perfect. It seems to regulate the state of equilibrium of the individual. 
and to preside over coordination. The mechanism of the labyrinthine 
canals is admirably described by Crum-Brown. 2 The sense of rotation, 
as suggested by him, must, like other special senses, have a special peri- 
pheral organ, a brain centre, and a connecting sensory nerve. All experi- 
menters agree that the labyrinth is a special peripheral organ, and the 
auditory nerve is that which conveys the peripheral irritation to the centre. 
" The bony canals are filled with liquid, in which float loose connective 
tissue, and the membranous canals with the contained endolymph. Uota- 
tion of the head about an axis at right angles to the plane of a canal will 
then produce, on account of the inertia of the liquid, etc., motion of the 
contents relatively to the walls of the canal ; and tins may be expected to 
irritate the terminations of the nerves in the ampulla. If the rotation be 
continued at a uniform rate, fluid friction of the endolymph against the 
membranous canal, and of the perilymph against the membranous canal, 
and the periosteum will gradually diminish this relative motion, which will 
at last cease. We should therefore expect, as we have seen to be the 
case, that continued uniform rotation should be perceived less and less 
strongly, and that the sensation should at last die away altogether. The 
time required for this equalization of the motion of the canal and its con- 
tents will depend upon the rate of rotation and upon the dimensions of 
the canal and the amount of attachment of the membranous canal to the 
periosteum. These latter conditions are not the same in the three canals, 
and therefore we ought to find, as we do, that the rate at which the sense 
of rotation dies away is not the same for different positions of the head. 
Again, if the uniform rotation is stopped, the contents of the canal will 
continue to move on, thus causing an apparent rotation in a. direction the 
reverse of that of the original rotation, and this also will die away owing 
to friction." The irritation of the auditory nerves which occurs, is at- 
tended by anaemia of certain parts of the brain, which accounts for the 

1 Ferrier on the Functions of the Brain, New York, 1876. 
8 Journal of Anatomy and Phvs., May, 1874. 



128 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

reeling, dizziness, nausea, and other symptoms with which we are already 
familiar. 

Diagnosis. — Gowers, 1 in a paper before the British Medical Associa- 
tion, pointed out the liability of its confusion with gastric trouble. He 
calls attention to the fact that violent and repeated vertiginous attacks, the 
sense of movement or actual turning, tinnitus aurium, and deafness, are 
more suggestive of the auditory origin than of gastric vertigo. Gowers' 
cases were connected with affections of smell and taste, and at the same 
time in one there was a gastric ulcer. He made his diagnosis by the de- 
tection of loss of function of the right ear and by one-sided falling. It is 
often necessary to differentiate from petit mal, from apoplectic warnings, 
and from general cerebral anaemia. In the first there is rarely vertigo. 
but there is loss of consciousness of temporary duration, and there is some 
convulsive movement, though sometimes so slight as to be unrecognized. 
The presence of aural disease is enough to throw out of the question the 
other condition I have named. 

Treatment. — Large doses of quinine have been of service in these 
cases, and Charcot's'- experience with this agent is extremely gratifying. 

He recommends the energetic use of revulsives in vertigo, the cautery 
being applied over the mastoid bone three or four times a week. He 
gave sixty centigramme doses of quinine in one case for a period of two 
months with happy results, and a short time after the commencement the 
vertiginous attacks ceased. It is necessary to give the drug in large 
doses, and at the same time the aural disease should not be neglected. 

In the case of "J. 15." I combined infusion of digitalis with the 
quinine, and obtained very good results. He was also directed to turn 
in an opposite direction to that caused by the disease. Subsequent expe- 
rience has convinced me that strychnine is perhaps better than quinine, 
and I Lave been highly successful in relieving a case of much greater vio- 
lence in which increasing doses of the drug were administered. In this 
connection it will be well to call attention to attack? of malarial vertigo of 
a periodic character which arc sometimes encountered, and which re- 
semble auditory vertigo: quinine or arsenic is of course indicated. 

1 lb-. Med. Journal, Aug. 26, 1S7G. 

2 LeQOns SUr les Maladies du Syst. Nerv. No. 1. p. 821. 




INTRACRANIAL THROMBOSIS 120 



CHAPTEE IY. 

OCCLUSION OF INTRACRANIAL VESSELS. 

THROMBOSIS EMBOLI SAL 

The deprivation of an area of greater or less extent of its blood-supply 
constitutes a condition which lias been called by some writers " Local 
cerebral anaemia," and it may take place through the existence of either of 
the above vascular states. Though very closely allied, these two forms of 
mechanical obstruction may be defined : in one case, as the local for- 
mation of deposits, or morbid changes favoring obliteration of bloodves- 
sels ; and in the other, as the lodgment of clots, or organized tissues which 
have been brought from a distance. Their chief interest lies in the fact, 
that it is often difficult for us to distinguish the subsequent symptoms 
from those indicating an effusion of blood from a ruptured vessel ; that 
speech troubles are prominent ; and that the prognosis is nearly always 
unfavorable. Thrombosis and embolism, though usually followed by many 
of the same symptoms, and confounded with each other by some of the 
medical writers by whom they were first described, differ greatly in their 
manner of occurrence and pathology. The first, as we shall hereafter see, 
is of slow development, and is not so serious in its results as embolism, 
while the latter condition is much more grave in all its features. 

INTRACRANIAL THROMBOSIS. 

Any local vascular change from the normal state which favors the depo- 
sition of fibrine in an intracranial vessel, whether it be an artery, a vein. 
or sinus, produces the condition which is known as thrombosis. As a con- 
sequence, the calibre of the vessel is narrowed, and circulation of blood is 
impeded therein ; clots form, and either from actual obstruction of direct 
supply or by pressure, a region of greater or less extent becomes anaemic. 
Though the arteries are more frequently the seat of such an alteration, the 
veins and large sinuses and the capillaries may he plugged up by clots 
which are of local origin. The condition, however, last mentioned is for- 
tunately a very rare one, but when it is met with it is a most dangerous 
and alarming morbid state. 

THROMBOSIS OF Tin: CEREBRAL ARTERIES. 

Symptoms It is a disease of slow development, and may affect 

Beveral arteries simultaneously, or but one. For weeks, or even months 



130 OCCLUSION OF INTRACRANIAL VESSELS. 

before, distressing and important evidences appear, and the patient may 
present unmistakable expression of the cerebral change, such as headache, 
which is generally localized, confusion of ideas, and awkwardness of 
speech, these disturbances being, usually, varieties of aphasia. As the 
disease advances this trouble becomes much more pronounced, and in 
place of there being simply a difficulty in expressing a clearly origi- 
nated idea, there may be a condition of amnesia. Clumsiness of speech, 
and want of delicacy in articulation are followed by an actual failure in 
remembering words. Memory is also defective in other things, and our 
patient begins to become stupid and listless. The next indication of this 
advance may be the appearance of paralysis, which is sometimes slight or 
incomplete, only involving the muscles of the face or eyeballs, or there 
may be hemiplegia. Should the thrombus be seated in a large artery, or 
softening occur, a complete and lasting hemiplegia may be produced. 
There is rarely loss of consciousness at any time, and in very few of the 
cases that recover, is there anything at all like the paralysis following 
cerebral hemorrhage. 

Kecovery is generally to be looked for, provided the vessel be not an 
important one; and, though like its first cousin, embolism, it may be 
one of the causes of softening, such a termination is not always to be 
feared. Aphasia, which is insisted upon by most writers as a pathog- 
nomonic sign, is occasionally absent. In one case reported, though the 
left middle cerebral was affected, there was no aphasia at any time. 1 

The following case is one that came under my observation, and is of 
interest because of the seat of the thrombus, and the interesting character 
of the morbid appearances. 

L. C.| aged 22 years, seamstress; admitted into hospital October 9, 
L876. History from friend who accompanied her. The patient had been 

feeling unwell for about two months, having had pains in her head and 
back. Loss of appetite, insomnia, and other troubles. About a week ago 
the friend went up to her room to assist her to drgss for breakfast. When 
the patient Stepped out of bed she fell upon the floor, and then first noticed 
that she was Completely paralyzed on the right side. The friend knew 
nothing of the patient's antecedents. Her husband, who was seen subse- 
quently, stated thai he had left her because she drank; and that after the 
separation sheweni to New 5Tork and became a prostitute. Two years ago 
he -aw her, and at that time sh<- had marks of syphilis on her face, and 
her hair was tailing out. She went to Ward's Island for treatment. She 

conversed with him intelligibly, but -aid she was suffering from "general 

debility." She had headache, pain in the back, etc., and was at this time 
leading a \<rv irregular life; sitting up during the greater part of the 
night, and sleeping only a portion of the day. The following history was 

taken by Dr. Naylor, resident physician in hospital: — 

Oct. 10. Complete hemiplegia of the right side, limbs lax, and muscles 
flabb\ ; impossible to excite reflex movements by tickling; right pupil 

1 St. George' i Hospital Reports, vol. i.. 1866, vol. vi. p. 822. 



THROMBOSIS OF CEREBRAL ARTERIES. 131 

irregular, and smaller than the left; tongue drawn to left side when pro- 
truded, and when she laughs the right side of the face is drawn up. Con- 
trol over the sphincters good; temperature 101°; patient aphasic. When 
asked, " How long have you been sick?" replied, "Since Benny;" this 

answer was given to many questions asked. "What do you hold in your 
hand?" (it was a piece of bread.) "Tobacco." Seemed puzzled, but 
when reminded of its true nature she brightened up and appeared to realize 
her mistake. 

13th. In about the same condition. Muscles of the right arm and leg 
do not respond to the currents. When asked how old she was. replied, 
" So and so." " What did you work at ?" " So and so." " What 81 reel 
did you live in?" Appears puzzled. "Was it sixteenth? seventeenth? 
eighteenth?" "Yes." "How long has it been since you last saw your 
mother?" "You long so, John." Expression intelligent, and she seems 
to understand all that is said to her. Does not hear so well on left side. 
with right ear perfectly. 

17th. Appeared to be suffering great pain. When asked to locate the 
pain, she did not attempt to do so. She has passed no urine since yester- 
day morning, lias a hard and swollen erythematous spot on the outside 
of each knee, and two similar enlargements on each leg below. There is 
a hardened red spot over the fourth cervical vertebra. All of these parts 
are painful to pressure. v 

18th. Right hand somewiiat swollen. G P. M. Is drowsy this evening. 
Appears to suffer pain, and places left hand upon abdomen. One pint of 
straw-colored urine containing no abnormal constituents was drawn by the 
catheter. 

19th. Still dull and drowsy. Said nothing to-day but " yes," " no," and 
"well;" passed her urine in bed ; stupid and dull all day. Carotid on 
right side pulsates very distinctly. 

21 st. Somewhat brighter to-day ; bowels regular. 

22d. Relapse to stupid condition ; passed urine in bed ; became choked 
while eating some beef at dinner. 

23d. Seems to take no interest in anything that is said to her. 

24th. Two furuncles (one surrounded by a red areola) have appeared 
on the right buttock. 

25th. Still absolute loss of power and sensation on right side, and con- 
tinued drowsiness. 

2Qth. Involuntary discharges of feces and urine. 

27th. She brightens up after receiving nourishment, but cries and seems 
distressed. 

2'.)//^, 2 V. M. Nurse called the house physician, seeing that she appeared 
to have stopped breathing. Her eyes were turned upwards and her lips 
blue, and her pulse was very weak and feeble. Ordered stimulants. 

Nov. 1. Made no attempt to speak, but answered "yes" or " no" cor- 
rectly to any questions asked. 

2d. Feverish and restless; temperature 101°: discharges from the 
bowels have stopped. 

(')///. Complains of pain in her thigh and legs: cries a great deal ; refuses 
food, and appears to be very much run down. 

%th. Right pupil approaching more nearly the size of the let't : appetite 

still good ; bowels regular. Cannot write her name with the left hand, but 
makes a disorderly scrawl. Asked her to repeat several words ; pro 



132 OCCLUSION OF INTRACRANIAL VESSELS. 

nounced " eggs" very distinctly ; for " cross," she said " cork." 7 P. M. 
Quite feverish and restless; temperature 102°. 

18th. Has still fever; temperature 102°. Ordered quinine and cold 
Bponging. She cries, and appears very sensitive when moved. 

14th. Slept well last night. 7 P.M. Temperature 100°. Several inguinal 
glands on the right side are somewhat enlarged and painful on pressure. 

22d. Complains of great pain at the attachment of the adductors to 
femur. 

The month of December was passed without anything occurring of spe- 
cial note. The patient grew much more feeble ; there was no improve- 
ment in the paralysis, and she became reduced to a shadow. The tem- 
perature continued elevated, and she was restless and delirious at times. 
Of course the burden of her delirium consisted of two or three words, 
which were repeated over and over. 

Jan. 8, 1877. Dr. Naylor was called to see the patient at 4 o'clock P. 
M. lie then noticed some fibrillary contraction about the right angle of 
the mouth, with an occasional spasm of the upper lip, when it would be 
drawn up with the wing of the nostril. Eyes closed, pupils more con 
tracted than usual, face flushed and head hot ; temperature in axilla 101 J°. 
When left foot was pricked she turned it up ; pulse too rapid to count ; 
heart's action tumultuous. Tr. digitalis, gtts. xv. 5 o'clock P. M. 
Spasm of lip still continues; lies on her back with eyes closed, and gives 
no evidence of pain when any part of the body is pricked ; pulse in same 
State. 6 o'clock P. M. Breathing heavily ; eyelids closed and eyes turned 
upward ; pupils do not contract to light, but lids contract slightly when 
conjunctiva is touched; reflex irritability very much impaired; pulse 100; 
temperature 102°. 7 o'clock P. M. Spasm of mouth has ceased ; respi- 
ration very slow and feeble ; pulse 80 ; temperature 102°. lOo'clock P.M. 
Mucous rales heard over whole chest. 12 o'clock A. M. Patient remains 
unconscious. 2 o'clock A. M. Patient still breathes slowly and feebly ; 
small amount of frothy mucus comes out of her mouth ; patient remained 
in this condition until death, 10 A. M., 9th instant. 

Autopsy Head : dura mater normal ; sinuses empty ; moderate effu- 
sion into arachnoid cavity; pia mater intensely congested; left middle 
cerebral artery about \ inch from its origin occupied by a firm thrombus; 
beyond this the artery was thin, ribbon-like, scarcely perceptible, and 
finally lost; membranes readily detached from the brain, leaving the 
sulci gaping widely over the under surface of anterior lobe, left side 
about third frontal convolution and island of Reil. In detaching the mem- 
branes portions of brain-subslance were removed with them, leaving an 

almosl pultaceous mass exposed; indeed the whole of under surface of an- 
terior lobe was much softened, but this was most marked near the lateral 
border; under surface of middle lobe slightly softened ; superior and lateral 
aspecl of anterior and middle Lobes from fissure of Rolando forwards was 

in a \ery BOftened condition, breaking down under the leasl pressure, of a 
pah- yellowish-gray color, in marked contrast with ot her parts of the brain, 

which on Bection showed very numerous puncta vasculosa, and were of the 
normal color. Thalamus opticus somewhat softer than thai of the right 

Bide; COrpUS striatum much softened and of a yellowish color. Thorax: 
lungs (edematous, and poured OUt an abundance of mucus on see I ion. 1 1 cart : 

insufficiency of mitral valve; no vegetations noticed; loft ventricle entirely 
filled by a firm while clot entangled in chorda tendinse and projecting 
into aorta i abdomen, kidneys, Liver, ancTspleen much congested. 



THROMBOSIS OF CEREBRAL ARTERIES. 133 

Causes Men are more often subject to arterial thrombosis than 

women or children, though we find the great number of cases of thrombosis 
of the sinuses to be among women, and this is perhaps due to the tendency 
of this sex to chlorosis. 

Gintrac considers very young children to be subject to venous throm- 
bosis. Of 37 cases seen by him, 14 were among infants ; but arterial throm- 
bosis is a condition peculiar to advanced life, and instances before middle 
age are not at all common unless they be of a specific nature. The ex- 
citing causes are numerous, but it maybe assumed in nearly every instance 
that the blood is in a state of hyperinosis as a consequence of acute disease, 
such as rheumatism or pneumonia. Excessive heat is very often a cause. 
Dickinson 1 gives four cases, in two of which heat was the cause, in one 
other intemperance, and in the fourth violent vomiting. 

In many of these patients there is old heart disease with some enfeebled 
action of that organ. The basilar artery, which receives its blood from 
the vertebral arteries, may be the seat of a clot at its remote end when 
heart force is preternaturally weak, but this is a rare form of the disease. 
I have already spoken of peripheral phlegmatous troubles, and it is only 
necessary to call attention to the danger which may arise from carbuncle. 
The puerperal state favors the formation of thrombi, and just as phleg- 
masia alba dolens is brought about, so may the thrombosis of the cerebral 
arteries be produced. The graver variety of intracranial thrombosis may 
be produced by internal or external cause. Lancereaux collected 39 cases, 
30 of which were connected with caries of some of the cranial bones, and 
24 with otitis. In one-half of these cases there were multiple abscesses of 
the brain. 

In conclusion I would allude to the possibility of traumatic origin, a 
variety of blood-states, and pressure from intracranial tumors, exostoses, 
and thickened meninges. 

Morbid. Anatomy and Pathology Von Dusch, Parnum, 2 

Grissole, 3 Zahn, and a host of observers have devoted themselves to the 
study of this subject, and since the original observations of Kirkes 4 were 
published in 1852, which were devoted to the pathology of thrombosis as 
well as embolism, a great deal has been written. Parnum and Burrowes 5 
both experimented by injecting substances into the circulation, and Bur- 
rowes probably relates tin 1 earliest case of recognized thrombosis. 

Zahn gives the following concise description of the pathological process 
which attends the production of a thrombus. " The intensity and the dura- 
tion of the injury, together witli the previous condition of the individual, 
determine the durability of the clot. The process of formation is the fol- 
lowing. Colorless blood-corpuscles adhere to a part of the intima denuded 

' Loc. cit. 

2 Virchow's Archiv, xxv. 8-6, pp. 308-338, t;;:i, :>.':<>. 1862. 
• 3 Pathol. Intern., p. 247. * Med. C'liir. Trans. 1852. 

5 Med. Gaz., vol. xvi. 1834-5. 



134 OCCLUSION OF INTRACRANIAL VESSELS. 

by an injury of its endothelium. They accumulate there, form a ring- 
like obstruction, and gradually the clot obstructs the vessel altogether. If 
the injury be slight, and the nutrition of the individual unimpaired, the 
current of blood soon breaks through the blood-clot and carries along the 
flakes of the colorless blood-corpuscles. The normal condition is soon 
restored. If the injury of the vessel be more severe, and the surrounding 
tissue alreadv in a state of irritation, the thrombus, whilst forming in the 
same way as described, is tinner and larger. The obstruction is more 
complete, and lasts for twenty-four hours and more ; after that period the 
thrombus begins to disintegrate into granular fibrine, the outlines of the 
blood-corpuscles composing the thrombus cease to be visible, and thus an 
uninterrupted circulation is re-established." 1 In more serious trouble the 
detached clots may be the nuclei of larger ones in the sinuses if the con- 
dition of the arterial walls be such as to favor more extended formation of 
thrombi so that the vessels become entirely occluded. 

The consequence of arterial occlusion is the formation of an extended 
clot which blocks op the vessel more fully, and consequent iscluemia of 
distal parts. Through the agency of outside vessels collateral circulation 
i- generally established in a short space of time. If, however, the anato- 
mical site be such as to interfere with this provision of nature, softsning 
or tardy degeneration will ensue. This softening, when it follows, is ex- 
pressed by a series of changes, which occur about as follows : Red soft- 
ening in from 24 to 48 hours, while the yellow change does not take place 
until after 14 days. But of this condition of affairs I will speak in a sub- 
sequent chapter. The carotid arteries and their termination are more 
often affected, and basilar vertebrals, anterior cerebral, and posterior com- 
municating come next, in the order I have given them. The pathological 
processes in the second form of intracranial thrombosis, viz., that affect- 
ing the sinuses and veins, are much more gross. Either through sluggish 
circulation of the blood on the part of a weak heart, pressure upon a sinus, 
Or unusual density of the blood, coagulation occur*, the arterial flow is in- 
terfered with, a part of the brain is deprived of blood, and serum is effused. 
If the disease be due to outside causes, there may be an extension of in- 
flammatory action from without in the manner I have described. By an 
extension of thrombosis, a form of meningitis resembling tubercular men- 
ingitis may be produced. Several of these cases have been seen by Seuch. 2 

An artery which is the seat of a thrombus presents these appearances: 
The inner coat is rough and perhaps corrugated ; the artery as a whole 
may he hard and discolored, with diminution in calibre and a deposition 

of recent or ancient dale, in which latter case it will he pale and tough, 

while atheroma is uol uncommonly present. Fox 8 has observed that the 

pari of the clot adherent to the inner coat of the vessel is much more dense 

than thai nearest the centre. When the capillaries are implicated, they 



1 Virchow'a Archiv, Band lxii., ^iefl L, Nov. 1874. 

2 Verhandlung dur Win/., p. Med. Geselschaft, viii. 17!). 
:l Path. An.it. of the Nervous CeSVes, p. 82. 



THROMBOSIS OF SINUSES AND VEINS. 135 

are generally found to be hard and calcareous. In thrombosis of the large 

sinuses or veins, the morbid appearances are much more striking. The 
thrombi are large, and, if old, of a gray color, and it is not rare to find 
pus, effusions of serum into neighboring parts, and perhaps some menin- 
gitis. Von Dusch has collected 57 cases, which are given by Fox. 1 In 
32 the thrombosis resulted from gangrenous, erysipelatous, and other in- 
flammations of the body (chiefly of head). In 1 foreign bodies were 
found. In 15 it appears to have resulted from asthenic circulation. In 
6 cases nothing positive could be ascertained. 

Diagnosis There are very few conditions with which that under 

consideration may be confounded. AVlien we remember thai in throm- 
bosis the development of symptoms is gradual, the loss of speech incom- 
plete, and primary; and in cerebral hemorrhage the onset is sudden, the 
aphasia is secondary to a loss of consciousness, and the paralysis more 
marked, the diagnosis from this disease is not so difficult. Doubts may 
arise in our minds when we are to decide whether or not the case before 
us is one of thrombosis or uncomplicated softening. Thrombosis is rarely 
attended by marked elevation of temperature, while the opposite is to be 
observed in cerebritis, which presents as symptoms trembling and per- 
haps muscular rigidity. The psychical symptoms are also more strongly 
marked. The more serious form can be diagnosed by the coexistence of 
other conditions which may favor its origin. 

Treatment. — The chief indication seems to be: The improvement 
of the condition which influenced the production of the thrombus. If 
arterial tension be at all weak, we may combine digitalis and iron (F. 21), 
give tonics (FF. 40, 43, 8, 9, 10, 32), and improve the patient's general 
condition by good food and stimulants. Nature will arrange the process 
of collateral blood-supply, and we may aid her by enforcing rest and quiet. 



THROMBOSIS OF SINUSES AND VEINS. 

When a large sinus or vein is involved, the resulting symptoms are 
much more complex and difficult to diagnose. 

Lancereaux, 2 who has written quite extensively about this form of dis- 
ease, has divided it into two grades, in regard to the variety of morbid 
action. One of these is inflammatory, the other is non-inflammatory. 
The first form is dependent upon the extension of some inflammatory pro- 
cess, usually from the ear, while the other is attended by coagulation of 
the blood in sluggish circulation. 

Von Dusch 3 does not agree witli him, but Tonnele, quoted by Grisolle, 4 
makes the same varieties as Lancereaux. 



1 Loc. c it., i). 85. 

2 Lancereaux, I >e la Thrombose, etc., Paris, 1862. 
:t Zeits. Air Ration. Med.. B. vii., L859, p. 11. 

4 Op. cit., tome ii. p. 240. 



136 



OCCLUSION OF INTRACRANIAL VESSELS. 



The seats of this pathological condition are the longitudinal, lateral, 
basal sinuses, and the large veins communicating therewith. Bastian 1 
alludes particularly to the longitudinal sinus as the most common seat, and 
describes the tendency to plugging up of the cerebral veins on both sides. 

As I have said, the symptoms are very obscure, but in every case we 
may consider them to be the indication of pressure. Headache, delirium, 
coma, convulsions, ocular troubles, and generally death in a very short 
-pace of time mark the course of the disease. Mr. Tuckwell 2 reports a 
case which is a representative of the anaemic form. It is as follows : — 

Eliza C, at. 10. was admitted to Radcliffe Infirmary on the 20th day 
of April, 1871. She ceased working a month before on account of palpi- 
tations, shortness of breath, weakness, irregularity of the menses, etc. 
Two weeks before admission she began to suffer from violent headache. 
She never had fits. A condition of decided chlorosis was diagnosed. 
There was a systolic murmur at base and venous murmur in the neck ; 
nothing else abnormal was detected. She was put to bed. 

April 21. She sat up, but it was noticed that she lolled about in a 
strange manner, and seemed stupid. Her right hand and arm were weak, 
and she could not raise them to shake hands. Headache still severe. 

21th. Remained in same apathetic state ; the paralysis of arm had 
increased, and she could not move fingers or hand at all; headache. She 
became comatose, and died after the visit of Dr. Tuckwell and his col- 
league, Dr. Palmer. 

Autopsy tw r enty-four hours after death. On removing skullcap, the 
dura mater covering right hemisphere was found to be of a dark color, 
and the longitudinal sinus, when examined, was found half way blocked up 
by a firm white blood-clot of some age. Cerebral veins on the surface of 
the middle and posterior part of right hemisphere were all occluded by 
dark clots. On removing the brain, blood was found effused in the right 
middle cerebral fossa, extending down into the spinal canal. 

Lateral and basal sinuses were filled with clots of some age. The pons 
and medulla were covered by a clot of recent date. General softening of 
the brain was observable, the optic thalami and corpora striata being par- 
ticularly affected. The arteries were all healthy, as well as the bone 
about the sinuses. 

Another case is reported by Dr. Tuckwell, which presented symptoms 
which were very much like those of his own case. 

You Dusch 8 has spoken of epistaxis with thrombosis of the longitudinal 
sinus as a common symptom, and Meissner has called attention to grind- 
ing of ih<' teeth, profuse diarrhoea, and exhaustion, together with certain 
changes in the configuration of the head. In children he has found <le- 
pressed fontanelles, lapping of cranial bones, and unequal distension of 

the jugular veins. Metastatic abscesses, indicated by local symptoms, 

have been found by many observers. Lanoereaux estimates that nearly 
half of all the cases are thus complicated. I have seen one case where 



1 Bastian, Common Forms of Paralysis, etc., p. 22. 

2 St. Bartholomew's Hospital Report^ vol. \., 1874, p. 
1 Loc. '-it. 



:;;>. 



EMBOLISM OF THE CEREBRAL VESSELS. 137 

erysipelas was undoubtedly the cause of the cerebral thrombosis, and after 
death the great sinuses were found to be filled with semi-purulent matter, 
and there were abscesses in the liver and other parts of the body. These 
cases are not so exceptional as they are generally supposed to be, but 

diagnosis before death is rarely made. 

An autopsy made at the New York Hospital by Dr. Ammidown, who 

kindly invited me to be present, revealed the following beautiful evidences 
of thrombosis of the cerebral sinuses which followed septicaemia : — 

The boy had died after several days' illness, the original injury being a 
compound fracture of the bones of the left leg. The autopsy was held on 
September 15th, the day of his death. 

The liver, kidneys, and lungs showed evidences of acute congestion, 
and the heart contained two ante-mortem clots ; one accupying the right 
auricle, and the other the right ventricle. The lungs were carefully ex- 
amined, and a pyramidal infarction was found at the border of the inferior 
lobe of the left lung. The head was open, and the dura mater was found 
to be quite healthy, except in the superior longitudinal sinus, which was 
almost completely filled with a well-organized thrombus of a pale color. 
One of the large descending veins in the parietal region was occluded, and 
when the dura mater was removed, a large pouch, filled with limpid and 
perfectly clear serum, was found beneath, which pressed upon the parietal 
convolutions just posterior to the fissure of Rolando. This was beneath 
the arachnoid. At no other point was there any abnormal collection of 
fluid, and in no place was there any evidence of structural changes of the 
brain-substance proper. The lateral sinuses were partially filled with 
thrombi, and contained some very fluid blood. The left petrosal vein 
was empty, as were others which were higher up. No arterial occlusion 
was found. The patient had died suddenly in convulsions with coma. 

Causes Blows upon the head, injuries of various kinds, extension of 

otitis, intemperance, and the causes I have already enumerated, may be 
mentioned. There seems to be no special dependence upon age or Bex, 
though it may be said that most of the cases occur during adult lite. 

What I have already said, and the excellent cases of Tuck well, which 
have been presented, render it unnecessary to say more about the morbid 
anatomy, 'pathology, or diagnosis. 

In regard to the prognosis, there can be no question. It is about as 
had as it can well be. As to treatment, the most we can do is to build up 
<»ui- patient, and reduce the danger of external disease by favoring a tree 

escape of pus if the original disease be otitis, and there be an accumulation. 

We may employ local cold and derivatives, but even these do little good 
after the disease is recognized. 



EMBOLISM OF THE CEREBRAL VESSELS. 

The cerebral arteries and capillaries are alike subject to this form of 

mechanical obstruction, but the former are perhaps the most common seat 



138 OCCLUSION OF INTRACRANIAL VESSELS. 

of the lodgment of fibrinous plugs. The little bodies which are forced into 
the vessels are always from some other part of the system, and are not 
formed in the vessel, as is the case in thrombosis. 

Embolism also differs from thrombosis in the fact that the latter is 
slowly developed, and attended by gradual narrowing of the vessel; while 
the condition under consideration is a sudden accident, and may occur in 
a perfectly healthy vessel: the converse is the rule in thrombosis. 

Symptoms — Unless there is previous acute endocarditis, there will 
seldom be any warning, the patient being suddenly stricken down as the 
little plug is violently forced into some vessel of the brain. There may 
even be no loss of consciousness, though this is the exception. Uncon- 
sciousness invariably occurs when a large embolon plugs up some such 
artery as the middle cerebral ; but if the embolon be small, and the artery 
occluded is one concerned to a very limited extent in the vascular supply 
of the cerebrum, the unconsciousness may be but transitory, and psychical 
symptoms of slight moment will constitute the sole indications of confused 
mental activity. 

The eyes are sensitive to light, the pulse is small and rapid, and there 
is usually pallor. There are no indications of pressure, no stertor, no 
tumultuous respiration, nor full pulse, and the pupils are either dilated or 
irregularly contracted. 

If the heart be auscultated, various murmurs or friction-sounds will in 
many cases be heard. Mitral murmurs are perhaps the most common. 

Paralysis taking the form of complete or incomplete hemiplegia is the 
result of such sudden arterial occlusion. 

Special facial muscles may be those affected, or various modifications of 
sensation, such as anaesthesia or hyperaesthesia, may be detected, but rigidity 
or contractures are rarely present unless there is secondary disorganiza- 
tion, and they are never seen during the early stages. Vertigo is a dis- 
agreeable and common symptom, and is sometimes attended by cerebral 
vomiting. Of course aphasia is an almost invariable consequence of em- 
bolism, as the middle cerebral artery is so commonly occluded. This 
aphasia is of variable extent, and is ataxic or amnesic, but generally the 
hitler. On the other hand, the patient may be simply stupid and taciturn, 
refusing to answer, or he may be troubled with a light form of clumsiness 
or slowness of speech. The headache, which is subsequent to the loss of 
consciousness, is coincident ordinarily with the re-establishment of col- 
lateral circulation, and if further changes occur there may he intense head- 
pain, delirium, mania, or symptoms indicative of softening. The duration 

of this Stage varies greatly. I have seen examples where the symptoms 
were trilling and transitory, such as headache, awkward speech, and 
paralysis <>!' one arm rapidly disappearing. ( )ther cases are correspondingly 
serious. .Mr. Shaw 1 reports a, case which proved fatal in twenty-four hours, 

and others have detailed examples in which death ensued in from thirty- 
si \ to forty-eight hours. 

1 Trans, of Path. Soc. of Condon, vol. iv. 



EMBOLISM OF THE CEREBRAL VESSELS. 139 

It is very common to find, at the same time, symptoms indicative of 
embolism of other organs. The spleen, lungs, and organs which rec 

a large supply of blood, or are in the direct line of arterial supply, are apt 
to be involved as well as the brain. It rarely happens that two or more 
cerebral arteries are simultaneously plugged. Iu such cases the symptoms 
are complicated. One case is recorded in which both middle cerebral 
arteries were occluded, and the following case reported by Sokolowski 1 is 
an example of coexisting splenic and cerebral embolism : — 

The patient was a servant, married, aged 23, who had always menstru- 
ated regularly, except when she was pregnant second year before, and 
then gave birth to a healthy child. Her health had been ordinarily good. 
Four days before her admittance to the hospital she had Buffered from 
alternate chills and heat, with headache and constipation. On admis- 
sion her pulse was 100; temperature, 102.(1 J . Heart friction sound 
at apex, but nowhere else. Passed 53 oz. urine in 24 hours; >p. gr. 
1025. 

October 13^/L She suddenly became paralyzed on the right side, losl all 
power of speech, and only moaned and cried in a frightened manner. The 
third day after, acute idiopathic endocarditis was diagnosed. The right 
ventricle was found to be greatly enlarged. Temp. 101.2° ; pulse, 100. 
After paralysis she lost hearing in the right ear ; pupils were normal ; left 
side of mouth was drawn up. Anaesthesia of paralyzed parts. Urine and 
feces passed unconsciously. Spleen tender and enlarged. An additional 
diagnosis was now made. Embolism of left middle cerebral artery, and 
embolism of splenic artery. The loss of speech was peculiar. She was 
unable to articulate at all, though there was sufficient evidence of mental 
activity and originating power, so she communicated with her friends by 
signs. The paralysis had begun to disappear in the right leg below the 
knee, and she could move her foot slightly. The temperature on the first 
day was 102.2° ; pulse, 90. In the evening, 104.8° ; pulse, 100. On the 
second day, Oct. 14, there was much improvement. The morning tem- 
perature was 102.8°, and the evening l()o.8°. 

15th. All paralysis and alalia have vanished. She is, however, i \- 
tremcly weak. During the next two or three days a diarrhoea, loss of 
appetite, and considerable increase of tenderness over the spleen appeared. 

28th. 35 oz. of urine were passed, which contained albumen, hyaline 
casts, and urates in abundance. 

November 10th. She has grown gradually worse, is no longer able to 
answer questions, but repeats words and sentences over and over. There 
is marked loss of memory. The fever has greatly increased, the evening 
temperature being 105.2° ; pulse 120, and quite thready. There are evi- 
dences of bronchitis and pulmonary difficulty. Urine greatly decreased in 
quantity, and albumen increased ; tongue quite dry. 

20th. She died. There was extensive hypostatic pneumonia : con- 
sciousness remained to end. 

Aiito]>s;/ Arteries at base healthy, except middle cerebral OD let't side. 

This contained a semi-transparent embolism of cartilaginous consistency. 

Right side of brain healthy, though pale. The left side in the sum' con- 
dition, excepl at the island of Reil, and grn\ mailer o\' lenticular nucleus, 



1 Deutsche Med. Woch., Dec. 15, 



140 OCCLUSION OF INTRACRANIAL VESSELS. 

which were small, hard, and yellow, and showed evidences of softening 
and subsequent cicatrization. The heart was enlarged, and yellow spots 
were found beneath the endocardium. The edges of the mitral valves were 
thickened and covered with coagula. The spleen enlarged, "blocked," 
and the splenic artery occluded. 

Cases have been reported where embolism followed, or was connected 
with, chorea, and this connection has been made use of in the explanation 
of the pathology of the latter disease. One of these cases, seen by Murchi- 
son, 1 is worthy of mention. 

The patient, a boy 14 years old, had suffered from chorea when seven 
years old, from which he recovered. Two weeks before he died, irregular 
choreic movements appeared, connected with a bellows murmur at the 
left apex. When seen, June 12th, the pulse was 120 ; temperature, 102°. 
There was a pericardial friction sound, but no pain in joints or other 
symptoms of rheumatism or endocarditis. 

June 28. Sudden unconsciousness, head drawn to right side, extreme 
rigidity, twitching on right side. Pulse, 145. Pupils normal and equal, 
but subsequently contracted ; no paralysis. Died June 29. Vegetations 
on mitral valves, spleen containing emboli. Left vertebral and left in- 
ternal carotid arteries blocked by pale, firm, and easily detached coagula; 
left hemisphere considerably softened. Examination revealed no small 
emboli in capillaries. 

A case of my own, showing an accident which may occur in the course 
of certain acute diseases, seems to me to be of sufficient interest to present, 
;i- it may call attention to a cause of death which is probably sometimes 
o\ erlooked. 

Air. X.. at. 35, a stout, full-blooded man of good habits and no vices, 
took to his bed on the 25th of June, 1874. 

lie had contracted a " bad cold" at the theatre, and the next day was 
sei/cd with pain in the left side, was chilly and uncomfortable, and when 
I saw him on the evening of the same day, he had a violent headache. 
His skin was hot. and his pulse hard and rapid. The thermometer indi- 
cated a temperature of 101° ; pulse, 122. At the base of the left lung 
crepitant rales were beard. Flaxseed poultices were applied, and quinine 

and Other remedies administered. For the next four or five days the 
lungs underwent consolidation, and nearly all of the physical signs con- 
nected with the different stages of pneumonia were observed. The most. 
marked of these was a high temperature, which ranged between 108° and 
in;, for six days. Resolution was slow, and but a few sputa were brought 
up. but the temperature had fallen to some extent. I was sent for in haste 

on tie- evening of the fourteenth day, an hour after my ordinary visit, to 
find that the patient had suddenly, while taking his beef-tea, fallen back 
unconscious, and hud remained so ever since. This was about half an hour 
before m\ being sent for. 

His pupils were widely dilated, and his comes when touched were sen- 
sitive ; his legs and arms were extended. His temperature was not high, 
and hi- breathing hud nol changed very much from what it was when I 
-;iw liim earlier in the day. 

1 London Path. See. Trans., vol. xxii. 



EMBOLISM .OF THE CEREBRAL VESSELS. 141 

After an hour and a half he made some movements which showed Blight 
voluntary control, and vomited, turning his head slightly to do bo. He 

uttered no sound.- except low moans. Towards morning his breathing he- 
came more troubled, and he rolled in the bed. 

At about nine o'clock in the morning of the next day he seemed to 
recognize those about him, and made signs which were not understood, 
when he knit his brows and seemed perplexed. He refused food, but 
permitted an enema of beef-tea to be injected, but this w;i< not retained. 
It was then found that he was hemiplegia on the right side. Later in 
the day he passed Ids urine in bed. 

16th day. Did not Bleep last night. The temperature 104°; pulse, 
1'iii, full and hard. After my visit this morning he became comatose. 
3 P.M., died. 

Autopsy 20 hours after death. — Lungs : right, rather more pinkish 
than normal ; some spots of induration at base. Left, solidified through- 
out most of its substance • when cut, bloody serum exuded. Heart some- 
what enlarged. Mitral valves were covered by stringy clots. The right 
ventricle contained a huge fresh clot. Kidneys: right, normal; left, 
somewhat smaller than it should be ; contained a small cyst beneath the 
capsule. Head: On opening the cranial cavity, the vessels of the dura 
mater were filled with dark blood. The longitudinal sinus contained a 
quantity of thick, clotted blood, which was almost black. The left hemi- 
sphere was (edematous, except at a point beneath the lateral ventricle, 
where there was a circumscribed patch of a pinkish hue, which seemed to 
be well defined. The left middle cerebral artery, at a point just before it 
gives off its branches, was found to be swollen and hard, and when cut 
open a small, rather firm clot was found. Behind this there was a Long, 
stringy clot of more recent date. About the vessel the brain was (edema- 
tous. Another patch of red softening was found in the same hemisphere 
somewhat more posteriorly. No other large arteries were affected, but 
when microscopically examined, I found considerable occlusion of many 
small capillaries, and great disorganization of the nerve elements. 

I have seen several other cases of this kind occurring during acute dis- 
eases attended by a hyperinosed condition of the blood. 

Causes Endocarditis is, above all other causes combined, the most 

important and common in the production of embolism. At the Patholo- 
gical Institute of Berlin 1 there were 300 cases of embolism of all kinds 
associated with endocarditis during the years included in the period b< - 
ginning 1868, and ending 1871. Twenty per cent, of these cases were of 
brain embolism. Of a large number of cases reported in the London Pa- 
thological Societies' Transactions, nearly all of them were o\' this nature: 
and out of fifteen cases I have seen, twelve were connected with disease 
of the heart, and generally with deposits upon the mitral valves. 

Croup, the puerperal state, phlebitis, and other conditions where there 
is any tendency to the formation of clots, or tin 1 detachment o\' tissue 
which finds its way into the circulating apparatus, may all produce em- 
bolism. 

Numerous accidents which happen through carelessness, or perhaps 

1 Edinburgh Med. Journ., July, Lfi 



142 



OCCLUSION OF INTRACRANIAL VESSELS. 



unavoidable injury during surgical manipulation, may, by the introduction 
of a blood-clot or foreign substance into the circulation, produce an occlu- 
sion of some cerebral or other vessel. This accident has occurred when 
pressure has been made upon large aneurisms, and is one of the arguments 
against the intravenous injection of substances which coagulate the blood, 
Buch as ergot, persulphate of iron, hair, or other organic substances. 

Dr. Barker 1 has given two cases of embolism following the parturient 
state, and Thomas lias seen one or more cases of this kind. 

A.S to age, I have found that more young people have had cerebral em- 
bolism than persons of advanced life. An examination of twelve cases 
reported by different observers gives the relative frequency as follows: — 



Between 10 and 20 years . 

20 " 30* " . 

" 30 " 40 " . 



Between 40 and 50 years 
" 50 " 60 " 



Of these, 3 were males, and 9 were females. 

Of my own cases, seven were between twenty and thirty; five between 
thirty and forty; and three between forty and sixty. Eight were women, 
and the Others men. It seems, therefore, that the period between 
the twentieth and thirtieth years is that in which the disease is most 
common, and that women are most subject to the disease. According to 
the observations of medical writers in general, mitral disease is more often 
an affection of youth or early life than of advanced years; so it seems 
probable thai people who have not reached middle life should be more 
subject to embolism. 

Diagnosis The important distinction is to be made when we suspect 

the cause to be one of cerebral hemorrhage. Next in order come throm- 
bosis, cerebral congestion, meningeal hemorrhage, and cerebral tumor. 

Gelpke 2 has given the following table, on one side of which are detailed 
the features of cerebral embolism; on the other, those of cerebral hemor- 
rhage : — 



CEREBRAL EMBOLISM. 

Youth of patient. 

Sudden onset, without prodromata. 

Previous articular rheumatism, val- 
vular sounds. 

Previous disease, which might lead 
to formation of (dots. 

The attack. 

Extensive muscular paralysis ; amne- 
sic aphasia. 

\Yr\ rapid ; or quite imperceptible 
disappearance of the residual disorder. 

Retention of early mental power. 



CEREBRAL HEMORRHAGE. 

Advanced age, atheroma. 
Prodromata generally present. 
Hypertrophy of left ventricle. 



The attack. 
Symptoms of cerebra] pressure; ataxic 
iphasia ; involvement of the intelligence. 
Disappearance of the residual dis- 
order after a moderate time. 
Reaction stage. 



1 Puerperal Diseases, p. 270. 

■ An-liiv der Heilkunde, xvi.,T\ug. iH7. r >, p. 485. 



EMBOLISM OF THE CEREBRAL VESSELS. 143 

Janeway 1 relates an admirable ease to illustrate the obstacles some- 
times encountered in making a diagnosis. As it will he seen in his case, 
there were many eireumstanees of a puzzling character which made tin- 
diagnosis exceedingly difficult. 

A young woman, while at work, fell to the floor unconscious, in what 
appeared to be a " fainting fit." There were some convulsive movements 
limited to the left side of the body. When admitted to liellevue Hospital 
on the following day, there were irregular contraction of the pupils, coma, 
and high temperature. Aloud systolic murmur was heard nil over the 
chest. She remained unconscious for two days, and on the third day 
died. Her breathing previous to death was stertorous, her limbs flaccid. 
and reflex action diminished. The pupils were dilated. Her urine con- 
tained a small amount of albumen, but not enough, in the absence of 
oedema and other symptoms, to suggest nephritic trouble; beside-, tin- 
quantity of urine passed was sufficient. The question of thrombosis was 
excluded by the absence of premonitory symptoms. Congestive chill. 
by the paralysis and meningeal hemorrhage, was suggested, but excluded 
when the absence of rigidity was taken into account. Janeway considered 
the lesion to be hemorrhage, and I will give his own description of the 
autopsy and its result. 

"The post-mortem examination revealed the following: Skull, normal. 
Brain and membranes: On opening the dura mater on the right side. 
a clot of blood, a little over half an inch thick, three inches long. 
and two inches wide, escaped from the arachnoid sac. This clot was 
in the main black, moderately soft, but provided with a huffy coat at 
one portion. It had produced a corresponding depression of the brain. 
over which it was situated, and in its centre was an opening about an inch 
long and a half inch wide, leading from a recent excavation in the middle 
lobe of the brain, through the torn pia mater and so-called arachnoid, into 
the sac of the latter. This excavation reached from the convex surface 
nearly to the corpus and optic thalamus at posterior extremity. The 
opening was situated a little nearer to the longitudinal fissure than would 
correspond to the middle of the convex surface. The excavation was 
about two inches wide and contained clotted blood, of which some had 
escaped in removing brain. The brain-tissue surrounding this was soft, 
slightly blood-stained, and where it formed the boundaries of the space, 
numerous black points were present, corresponding to clots of blood, closing 
numerous small torn vessels. The brain-tissue of the posterior lobe, espe- 
cially on its outer surface, was softer than natural. The posterior ex- 
tremity of the optic thalamus of tin' right side, over a. small area, presented 
an ecchymotic softened state. 

kk In the clotted blood and disintegrated brain-tissue found at the mouth 
of the excavation, a small branch of the posterior cerebral was found torn 
across, presenting a widened extremity at the point of rupture, surrounded 
by thickened and firm tissue, and in the interior of this a linn reddish- 
gray clot, uniform in its structure and of older date than any other-. I 
failed on careful examination to find the other extremity of the torn ves- 
sel, but from the condition of the portion found doubt not thai it would 



Am. Psychological Journal, Nov. 1876. 



144 OCCLUSION OF INTRACRANIAL VESSELS. 

have proved of similar shape to the other, and that together they would 
have constituted a cylindrical dilatation of this artery. 

" The left (opposite) hemisphere showed the convolutions flattened and 
so closely pressed together laterally as to nearly obliterate the appearance 
of sulci. The arachnoid was dry, and there was no sub-arachnoid fluid 
present. The brain on this side appeared anaemic, and on cutting the 
dura mater pressed out. 

" The lateral ventricles were of normal appearance. The anterior lobe 
of right side was normal. Pons, cerebellum, etc., were normal. The 
arteries at the base were carefully examined, being followed to their smaller 
ramifications without finding any emboli. 

" The lungs were slightly (edematous. 

"Heart: The left ventricle was slightly hypertrophied. On the auri- 
cular aspect of the mitral valve, and on the ventricular of the aortic, con- 
dylomatous excrescences were present, narrowing both orifices ; but the 
largest mass passed obliquely across the heart from the leaf of aortic valves 
nearest the septum to the anterior leaf of mitral valves, and above this, 
between it and the other leaflet of aortic valves, a slight dilatation of the 
heart-wall existed. 

" Small infarctions were present in the spleen and the kidney, and the 
latter showed at some points interstitial nephritis, around glomeruli, with 
atrophy of these ; but the disease was not advanced. The mesentery pre- 
sented two small aneurismal dilatations of little arteries, and at these 
points emboli were present: one was of the size of the head of a pin; the 
other, of a pea. 

" In this case it seems exceedingly probable that the primary lesion of 
the artery, which finally ruptured, was embolism, and that this obstruction 
caused, secondarily, a dilatation of the artery at this point, and that, 
owing to the heat, 1 such an obstruction of the circulation in the brain oc- 
curred as to cause the rupture of the vessel described. This is rendered 
still more probable by finding two small arteries in the mesentery with 
aneurismal dilatation, and containing emboli. 

" A point of interest in this case is the absence of serious symptoms of 
cardiac disease, though there was so marked a lesion. It did not seem 
:i- if any regurgitation had occurred at the aortic orifice, simply obstruc- 
tion. The left ventricle contained such a firmly adherent clot thai the 
hydrostatic test was of no avail. 

"It also furnishes another to the already long list of cases in which a 
heart-murmur i> heard — sudden paralysis occurs — the patient moderately 
young, and yet the lesion is hemorrhage, and not embolism. I have met 

with several of these exceptions." 

From thrombosis there will be no difficulty in making a diagnosis when 
we remember the slow origin of the former. The " apoplectic form" of 
cerebral congestion Bometimee resembles the condition presented by the 
patient; however, the former history, the suffused face, contracted pupils, 
and rapid subsidence of symptoms, will put us on our guard. 

1 The weather was excessively warm at this time, add the patient was at first 
supposed bj those around her to he suffering from the effects of the heat. 



EMBOLISM OF THE CEREBRAL VE88EL8. 145 

Morbid Anatomy and Pathology Burrowes and Kirkes were 

the first English writers and Virchow the earliest Continental writer to de- 
scribe these conditions. Prevost and Cotard have since related interesting 
experiments. They injected tobacco seed into the carotid- of dogs, and 
afterwards watched the changes that followed. One of these dogs was 
killed thirty-nine days after the seed had been introduced, when they found 
the middle cerebral artery obstructed, and induration about the fissure of 
Sylvius. 

The pathological processes which follow such mechanical obstruction 
have been sufficiently noticed in a preceding article, so it will be enough 
to call attention to the fact that the consequence of such an accident will 
be softening of the parts deprived of their nourishment, unless the collat- 
eral circulation be established at an early date, or the embolon is broken 
down and removed, which is a very unlikely circumstance. 

Kirkes 1 calls attention to the distribution of emboli in the following 
words: "The parts of the vascular system, within which these transmitted 
masses of fibrine may be found, will of course depend in a great measure 
upon whether they proceed from the right or left Bide of the heart. Then, 
if they have been detached from either the aortic or mitral valves, they 
will pass into the blood propelled by the left ventricle into the aorta and 
its subdivisions, and may be arrested in any of the systemic arteries or 
their modifications in the various organs, especially those which, like the 
brain, spleen, and kidneys, receive large supplies of blood directly from 
the left side of the heart. If, on the other hand, the fibrinous masses are 
derived from the pulmonary artery and its subdivisions within, the lung- 
will necessarily become the primary if not the exclusive seat of their sub- 
sequent deposition." 

In regard to the side of the brain where the deposit occurs, I think we 
may say that the left side and the middle cerebral artery are the most com- 
mon site, though many cases reported by Shaw, Glynne. Murchison, and 
others prove that the right artery may be affected as well. 

An interesting example, which is almost unique, is the following case 
of embolism of the right posterior cerebral artery, The history was read 
by Broadbent before the London Clinical Society: — 2 

"The patient, a young man aged 19, had suffered three years previously 
from acute rheumatism. Ten days before his admission, he suddenly be- 
came blind, and had great pain in the head. Five days later, vision hav- 
ing returned, he lost the use of his left limbs, while the right arm and leg 
were continually in motion; and, unless restrained, he rolled over and 
over towards the left, falling out of bed and bruising himself severely. 

The lefl hemiplegia and uncontrollable movements of the right limbs con- 
tinued when he was admitted; the hemiplegia not being absolute, but 
accompanied by slight rigidity and very considerable impairment of sensa- 
tion. The patient took no notice of persons or objects, but answered ques- 
tions, and put out the tongue on being urged. Hi- pulse wa8 variable, 

1 Royal Med. Clin. Trans., vol. sxxv. p. 281, L852. 

2 Abstracted from Lancet. Monthly Abstract, April, 1876, p. .">7U. 
10 



146 OCCLUSION OF INTRACRANIAL VESSELS. 

120 to 160 or more. Temperature in the right axilla, 99.2°; in the 
left. 100.6°. A loud mitral systolic murmur was present. The bowels 
were confined, and. when opened, the feces and urine were passed in bed. 
A dose of three grains of calomel was given, and two grains of carbonate 
of ammonia with two drachms of infusion of digitalis every two hours. 
Chloral also was given at night. He was ordered a diet of milk and beef- 
tea, with four ounces of brandy. There was gradual improvement; and, 
three days after his admission, an ophthalmoscopic observation, previously 
attempted in vain, was obtained, and the disks were found to present the 
appearances of marked ischaemia. The pulse was now 108, soft, short, 
and strikingly dicrotous. A day later the pulse was 88, and more full. 
The temperature was still nearly a degree higher in the left (100°) than in 
the right (99.2°) axilla. Slight paralysis of the left external rectus of the 
eye was observed. At the end of a fortnight's stay in hospital, the right 
limbs were quiet, and then? was considerable return of power and sensation 
in the left side. His speech was rather slow, but there was no obvious 
impairment of the intellect. Notwithstanding this, however, he not only 
passed his i'wc> in bed, but threw them about and bedaubed himself and 
the bedclothes without any regard to decency. The optic ischaemia was 
marked, but vision was good. The temperature of the right axilla was 
99.3° ; of the left, 100°. At the end of three weeks he passed his excretions 
naturally. After five weeks he was up and about, eating well; but pale, 
and still complaining a little of headache. Impairment of power and of 
Bensation in the left limbs was still perceptible. The optic neuritis was 
subsiding. Distant vision was good, but small print was not easily read. 
A systolic mitral murmur was heard. The temperature was still never 
below 99°; usually 100°; it was now equal on the two sides. But for 
this elevation of temperature, the patient would have been allowed to 
Leave the hospital. Soon afterwards, however, there were symptoms of 
splenic embolism, and later of ulcerative endocarditis; and he died from 
this four months after admission. On post-mortem examination, with 
ulcerative endocarditis and numerous recent embolisms, there was found 
softening of the occipital lobe of the right hemisphere from the posterior 
cornu of the ventricle downwards, and the branch of the post-cerebral 
artery entering the calcarine fissure was occluded and lost in adhesions. 
It was considered probable by Dr. Broadbent that originally the posterior 
cerebral artery itself had been blocked up, and not only this branch. The 
interesting points in the case, on which comments were made, were the 
temporary blindness, the agitation of the right limbs and rolling tendency, 
the usual association of loss of sensation and of double optic ischaania with 
embolism of a cerebral artery, and the remarkable indifference to decency 

persisting when the intellect was apparently good." 

Fat globules may sometimes plug up the small capillaries, producing 

wide areas of Boftening. 

The morbid appearances indicative of aerebral embolism are of interest 

and worthy of the closest study, not only because the brain is the point 

which Buffers the mosl seriously, bul because generally the heart, spleen, 
Lungs, bloodi easels, and other organs may be involved as well. On the valves 

of the heart, either mitral Or aortic, may be found excrescences, induration 

<>r recenl clots, and the arteries themselves mn\ exhibit patches of atheroma. 

In the brain We Will probably find one or more of the arteries I have 



EMBOLTSM OF THE CEREBRAL VESSELS. 147 

spoken of to be Bwollen, hard, and filled by one of these little mass 
fibrine. Tiny have been compared to grains of wheat, and resemble them 
very closely. Generally the embolon is separated from a second plug 
which has followed clotting of the arrested blood. Emboli are never 

attached to the walls of the vessels. 

Several arteries may, perhaps, he found obstructed in the same way. 
-• Sometimes all on one side ; at other times some arteries of one side ot* the 
brain, and some of the other," 1 -<> says Fox. 

Softened masses are generally found on examination, and are usually 
the cause of death. The parts behind the occlusion are subjected to the full 
force of blood which i- arrested, and not sent to the parts it should supply, 
and local hyperaemia is a result. The resulting softening is generally con- 
fined to the left hemisphere at its base, for reasons 1 have before stated, 
and the frontal convolutions, corpus striatum, and adjacent parts are found 
to be cither red or yellow, softened or indurated. 

(Edema of the brain is not an uncommon appearance, such oedema 
being seen in the parts deprived <>f blood. The perivascular spaces being 
enlarged, it is but natural that their fluid should rush in to till up the in- 
creased space left by the bloodless arteries. 

Prognosis The outlook for the patient is generally a very gloomy 

one if the accident be at all grave, and the artery be one of importance. 
The -everity of the symptoms, the existence of emboli in other organs, 
the (dement of severe pain, high temperature, and gradual development of 
symptoms indicative of softening are of unfavorable import, and give 
affairs a very dark look : therefore it is never well to make too hasty a 
prognosis. 

Treatment Rest, abstinence from stimulants, and agents which will 

diminish the arterial tension are the only remedial means to adopt besides 
the ordinary indications which appeal to the common sense and discretion 
of the medical man. Afterwards, resulting conditions, such as paralysis 
or softening, are to be treated. 



1 Op. cit.. p. 32. 



148 DISEASES OF THE CEREBRUM AND CEREBELLUM. 



CHAPTER Y. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (Continued). 
CEREBRAL SOFTENING. 

Synonyms. — Ramollissement (rouge, blanc, jaune). Encephalitis 
aigue, chronique (Fr.). Mollities cerebri, Encephalitis, Softening of the 
Brain (chronic, acute), Inflammation of the Brain. 

Definition. — A disease of the brain of an acute or chronic character, 
attended by destruction of nervous substance, and of an acute inflammatory 
nature, with purulent formation ; or of a chronic non-inflammatory charac- 
ter, with less rapid disorganization of nerve-tissue ; but in either case pro- 
ductive of a mollification of the nervous substance. 

So much confusion has arisen from an incorrect appreciation of the 
morbid anatomy and its connection with pathology, that it is a difficult 
matter to attempt the reconciliation of the many widely differing views of 
the legion of writers. "Inflammation of the brain" is the term which has 
led to all this confusion ; and I June been bold enough to base my classi- 
Gcation rather upon the character of tissue-changes than upon the arbitrary 
law that softening of the brain is the only result of inflammation. Sclero- 
sis, a- we know, is undoubtedly the result of a low grade of inflammation, 
but in this case the tissue-changes are quite different. 

Considering that the word ''softening" means a mollification, and thai 
it may result not only from purulent inflammation, but from low nutritive 
changes, I shall divide the subject as follows : — 

.. . D n, . ( Diffused Cerebritis. 

1. Acute bottening, } __ . .♦. 

, . ,, •< Meningo-Cerebrihs. 

(Inflammatory . i ^ ,-, , . . 

JJ (. Purulent Cerebritis. 

2. Chronic Softening, \ Primary Softening. 

( Non-inflammatory), ( Secondary Softening. 

1. Under the first head we may place the variety described by Elam, 1 
which is :i quite Pare affection in its uncomplicated form, that is, when it 
involves the brain substance en masse; and meningo-cerebritis, which is 
by I'm- more common. In a third variety the acute disease is characterized 
by purulent collections, and perhaps by thfi ultimate formation of abscesses. 

>. Chronic softening in its primary form we will consider to be depend- 
ent upon general disease, intellectual prostration, and like causes; while 

•• secondary — < > 1 1 < • 1 1 i 1 1 ^jl " ' may he used to express the form which follows 
vascular lesions, BUCh as embolism, thrombosis, or cerebral hemorrhage. 



1 Cerebria, and other Diseases of the Brain, London, 1872. 



ACUTE SOFTENING. 149 



ACUTE SOFTENING. 



In the first form it may be either cortical, diffused, or combined with 
meningitis. 

Symptoms Cerebritis of cither kind is preceded in nearly every 

instance by symptoms of functional disorder, such as cerebral congestion 
or cerebral anaemia, but these are not sufficient in themselves to arouse the 
suspicion of the observer as to the serious character of the disease which 
is to follow. The later prodromata of cerebritis, however, cannot be mis- 
taken, and finally the developed disease presents most pronounced symp- 
toms, which, if they do not always enable us to locate the brain lesion, are 
sufficient to assure us that some violent inflammatory process is under 
weigh in the cerebral mass. The patient may for some months suffer 
greatly from headache of a diffused character, accompanied by burning 
sensations, and a sense of pressure behind the eyeballs. These headaches 
are quite intense, and are aggravated by exposure to heat, concentration 
of the mental powers, and alcoholic indulgence. His memory becomes 
gradually enfeebled, so that at first dates and names are forgotten, and 
afterwards faces, locations, and even information -which may have been 
imparted to him a short time previously. Some slight clumsiness of 
speech may be indicative of the near approach of grave symptoms, but 
this clumsiness is not aphasic till later. Irritability of temper, restless- 
ness, and incapacity for mental application are attendant evidences of the 
smouldering fire which afterwards is to make itself known by still more 
decided symptoms. Among these may be enumerated nystagmus, stra- 
bismus, and diplopia, as ocular troubles; contractures of the limbs, 
tremors of individual muscles or groups of muscles, a twitching of the 
limbs, or other motor troubles, and hyperesthesia, followed by anaesthesia, 
and other disorders of sensation; these last sometimes being peculiarly 
prominent. Next we find that there may be an apoplectic attack or 
convulsions of an epileptiform character, which mark the violent stag 
the disease. Should there be, as a result of the morbid process, cerebral 
hemorrhage, it will be found that the paralyzed limbs become markedly 
contracted, and that rigidity is a striking feature. According to Jaccoud, 
the contractures may be bilateral, though the rule is the other way. the limbs 
of but one side being rigidly flexed. 1 He has seen one case where the 
left arm and leg were the seat of contractures, and where the face was 
Contracted and strongly drawn towards the left side, suggesting a right 
facial palsy, but the appreciable rigidity of the facial muscles of the left 
side left no doubt as to the origin of the deviation. The paralyzed mem- 
bers are generally those that are the seat of convul>i\e movements in the 
first place. The convulsions may be general, and assume an epileptiform 
character, and may be accompanied by vomiting. The patient's mental 
condition meanwhile undergoes a great change. Delusions, which somewhat 

1 Traite" de Path. Interne, vol, i.. art. Bnceph. algue. 



150 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



resemble those of general paralysis of the insane, are present; the exaltation 
di 'irante of the French, which is by some considered to be an early symptom. 
This lias not been my experience, and I am convinced that in the cases where 
it has been noticed as an early expression of the affection, the disease 
was probably general paralysis, and not cerebritis. Memory is abolished, 
and finally dementia remains, which, should the patient live tor some time, 
i-, expressed by all the other signs, drivelling of saliva, inane smile, hebetude, 
ami total imbecility, while there may be aphasia of the amnesic or ataxic 
variety. The muscles concerned in articulation and deglutition are in- 
volved, and the patient may narrowly escape being choked by the masses 
of food which " go down the wrong way " or accumulate in his mouth. 
Constipation or retention of urine is not an uncommon accompaniment, 
and the urine is charged with urates, is dark-colored, and rapidly under- 
goes decomposition. The temperature and pulse are both changed, the 
latter becoming accelerated and irregular, and the heart-sounds sharp and 
" precipitative." A tremulous character of the pulse has been noticed by 
several observers ; but I agree with Hammond that there is nothing dis- 
tinctive about this. The temperature may rise to 110° F., and generally 
attains its highest point at the end of the first four days. Coma precedes 
a fatal ending in the acute form at the end of a few days, and death occurs 
generally after seven or eight days by asphyxia. Should the patient sur- 
vive, there is a remission of the symptoms, and the formation generally of 
an abscess. Cerebritis does not always begin in the same way, and, as I 
have already stated, is not invariably symptomatized by all the forms of 
disordered functions I have enumerated. There may be no premonitory 
symptoms should the disease follow otitis or injury, but in the insidious 
form, which has been so admirably described by Elain and Reynolds, the 
appearance of prodromata is gradual and progressive. In certain cases 
the paralysis is an early symptom, in others the defects of articulation and 
deglutition are more prominent ; in other cases psychical disturbances are 
decided, while in still others coma, or convulsions are the striking features. 
The predominance of these different symptoms depends very much upon 
the region which suffers the most from the violence of inflammatory action. 
It must lie borne in mind that the disorder is attended from the lirst by 
febrile disturbances, and that all the symptoms are those indicative of a 

hypersesthetic state of the cerebrum. Should the patient survive the im- 
mediate violence of the attach, he may recover to some degree. The tem- 
perature and pulse are lowered ; the active evidence of the central disease 
Subsides, but it is not common for any amelioration of the paralysis to take 
place. The headache may become more localized and less intense, or mav 

Bubside altogether, and it may <>nl\ reappear when the patient is fatigued. 

lie ni:i\ remain in this condition for several years. In one case that came 
under my observation I accidentally found a large abscess about the size 
of ;i horse Chestnut in the white matter of the anterior lobe of the right 

hemisphere. The individual had died of phthisis, and during life com- 
plained <>t no Bymptoms which would dined suspicion to the brain lesion, 
lb had had a febrile attack six years liel'ure. which was probably the lime 



ACUTE SOFTENING. 151 

at which the abscess was formed. In many cases cerebral abscess follows 
disease of the temporal bone, and in the majority of instances it is not 
essentially necessary that there should be complicating general meningitis, 
though such is often the case. A very interesting history was presented 

by Dr. Elliot 1 to the New York Pathological Society. 

A man aged 50, of intemperate habits, for the last twenty years subject 
to constant headache, fourteen years ago had an attack of acute mania, 
lasting two weeks, and ten years ago a similar attack. For the hi-t four 
months vision has been failing, and there was an inclination to talk con- 
tinually, either to himself or the attendants. 

One month before death he was seized with general convulsions. A 
week later there was spasm of the left leg, attended with intense pain, 
alternating for three days with pain in the lumbar region, and imperfect 
paraplegia, terminating in paralysis of the left leg; this, however, passed 
off in twenty-four hours. 

One week before death there was convulsive action of the right side, 
with severe pain for two hours, succeeded by right hemiplegia. After 
thirty-six hours, motion was regained in the arm, but not in the leg. Dur- 
ing the last month of life there was constant vomiting. 

Autopsy There was found near the centre of the upper surface of the 

right middle cerebral lobe a thickening of the arachnoid, and beneath this 
an abscess of the size of an English walnut, with smooth walls. The 
brain-substance surrounding the abscess was condensed and gray, and 
around this again red and soft. In the centre of the right middle cerebral 
lobe, in the anterior and inferior part of the right posterior cerebral lobe. 
in the centre of the left middle lobe, and in the inferior part of the left 
middle lobe, were similar abscesses. 

The left lateral ventricle was tilled with pus coming from the abs< 
in the left middle lobe; the pus in all the abscesses was green and fetid. 
No lesions were found in the other organs. 

Causes. — Exposure to the sun's rays, alcoholism, inflammatory disease 
>f the bones of the head or face, meningitis, brain tumors, traumatism, 
and syphilis, as well as several of the zymotic fevers and rheumatism, are 
all predisposing and exciting causes of cerebritis. The simple form may 
)e idiopathic, but that which results in the production of abscesses is more 
)ften due to traumatism, caries of adjacent bones, or syphilis. Jaccoud 
las found that the proportion of patients in regard to sex was in favor of 
the males, nine men being affected to every four women, and that the dis- 
te was developed between puberty and the forty-lift h year. Cerebral 
tbscess or traumatic cerebritis may be produced, of course, at any age by 
injuries or the extension of other diseases. I have seen one case in which 
■rebritis followed otitis in a child ten years old. Lead poisoning should 
not be forgotten as a rare cause. 

Morbid. Anatomy and Pathology. — Cerebritis may either in- 
rolve the cortex cerebri or sonic central part-, sucb as the corpora striata 
>r optic thalami, or more rarely may affect the entire brain, but it prefers 
the gray matter, which is so richly supplied by bloodvessels. The brain 

iv be found to he the -eat of man\ -oftened part-, a- " t'<>\ era" of purulent 



1 Trans. N. V. Path. See., vol. i. p. 6. 



152 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

accumulation, serous exudation from the vessels, infiltrating the surround- 
in n brain-tissue, or there may be ruptured vessels, and an escape of their 
contents. The brain-tissue may be stained by the hematine, and occa- 
sionally present the appearance of simple non-inflammatory softening. 
The microscope enables us to see a multiplicity of changes — granular 
degeneration, leucocytes, broken-down nerve-elements, rarely neuroglia- 
thickening, and still more rarely amyloid bodies. I know of no more in- 
teresting Held for the study of morbid microscopical anatomy than a brain 
of this kind, for nearly every appearance or grade of diseased structure may 
be found. The vascular lesions are capillary hemorrhage, miliary aneu- 
rism, etc. Suppuration takes place in several ways. The brain-sub- 
stance may be generally infiltrated, so that it presents a yellow color 
throughout its extent, or there may be a localized infiltration or an en- 
cysted collection of pus. About the latter will be found a sclerosis of the 
brain-tissue, and about this a serous infiltration. Jaccoud has found that 
abscesses are more often to be observed in the white substance, in which 
conclusion he is supported by the observations of many writers. Lebert, 1 
in fifty-eight cases, found the abscess to be located twenty-three times in 
the left hemisphere, eighteen in the right, twice in the corpora striata, 
twelve times in the cerebellum, twice in the pituitary body, and once in 
the spinal cord. I have already presented cases which will enable the 
reader to appreciate the origin and size of such collections of purulent 
matter, and the evidences of diseased bone, fracture, etc., that are to be 
discerned in cases of traumatism or disease. In certain pyaemic condi- 
tions, such as erysipelas, abscesses may be found in other parts of the 
body as well, notably in the liver and lungs. In rare forms a rapid ne- 
crobiosis or "death" of tissues takes place, which is almost analogous with 
gangrene in other parts of the body, and large masses of brain-tissue are 
destroyed very rapidly. 2 

1 Virchow's Archiv, x. 18GG. 

2 Of fifteen cases of cerebral softening of the acute form, Camleil* found in one 
fibrine in the Binuses of the dura mater ; in one, this membrane was bathed in 
purulent liquid, and it was also perforated at one point; in five there were recenl 
spots of encephalitis on the right and left sides, in six on the left only, in three on 
the right only; in three there were cellular cicatrices in the right lobe of the 
brain, in one in the left lobe; in two the right hemisphere of the cerebellum was 
the seal of an acute inflammatory spot ; in four the principal recent inflammatory 
spots were still in a Btate of red hepatization; in seven they were in a state of 
softening, with disintegration of the aervous substance; in four they were in a 
Btate of disintegration of the nervous substance, with a mixture of a liquid that 
resembled pus; in four the spots of acute local encephalitis without clot were 
Btudied microscopically. Of these, in one they were still in the state of red 
hepatization ; the diseased regions were reddened by the widening of the capilla- 
ries, and l>\ the presence of extravasated globules of blood; the cerebral fibres 
were not yei disintegrated; already small granular cells had begun to be formed 
in the inflamed parts. In three the aervous substance of the diseased seats was 
disintegrated, and more or less reduced to fragments; it was soaked in plasma, 



Quoted by Fox. 



ACUTE SOFTENING. 153 

Diagnosis. — Cerebral hemorrhage, meningitis, cerebral tumor, embo- 
lism, and thrombosis are all conditions from which it is proper we should 
distinguish acute cerebritis and cerebral abscess. 

Some of the symptoms of general paralysis of the insane may possibly 
mislead the observer. From cerebral hemorrhage we are to distinguish 
cerebritis by the rapid amendment of symptoms in the former, while in 
the latter there is progressive evidence of advancing structural changes. 
Fever is not connected with cerebral hemorrhage, unless there be secon- 
dary inflammation of the brain-substance. The headache is not suggestive 
of cerebral hemorrhage, nor is the delirium or vomiting; and. after all, 
the only symptom which deserves attention is the paralysis. It ie impor- 
tant to bear in mind that rigidity and contracture take place before pa- 
ralysis, while we know that the converse is the rule in cerebral hemorrhage. 
Should hemiplegia follow a number of the other symptoms, we may consider 
that the hemorrhage is secondary to the cerebritis, and that some vessel 
has been cut across. It is almost impossible to distinguish uncomplicated 
cerebritis from meningo-cerebritis. The pain is perhaps more marked in 
the latter, and the convulsions are bilateral. In uncomplicated cerebritis 
there is not nearly so much fever as in the meningeal form or in simple 
meningitis. Typhoid fever may simulate cerebritis, and vice verso. 
Attacks of the latter begin with headache, vertigo, movements of the eyes, 
insomnia, delirium, nose-bleed, and diarrhoea, with high evening tem- 
perature. The absence of tympanites, and gurgling in the left iliac fossa, 
and the appearance of paralysis and visual disorders, are quite sufficient 
landmarks to prevent the diagnostician from losing his way. When there 
is suspicion of otitis or traumatism, it is exceedingly difficult to make a 
diagnosis from thrombosis of the cerebral sinuses, and it is fortunate that 
no value is to be attached to such a diagnosis, as far as therapeutical indi- 
cations are concerned. 

Prognosis. — There is very little hope for the patient, and should he 
survive the acute attack he is usually left paralytic and demented. If 
there be a purulent accumulation, which becomes encysted, the chances of 
recovery are very little better, and it only becomes a question of time 
when the patient will die. If there be such a cerebral abscess, subsequent 
Bymptoms very much like those connected with other brain tumors will be 
probably developed ; but, in numerous cases cited by various authors, .a 
Cerebral abscess has existed unsuspected for years. 

Treatment. — Acute cerebritis in either form must be met with ab- 
straction of blood, cold effusions to the head, agents which lower vascular 
tension, counter-irritants, and mercury in some one of its tonus. The 
ice-hag, or the apparatus already alluded to for the application of cold 
water, may be used, and Leeches are to be applied to the arms or behind 

the ears. Jaccoudand mosl of the clinical teachers recommend purgation, 

mixed with m considerable number of great cells collected together, and molecular 
granules; sometimes in the preparation there were seen pare globules of pus scat- 
tered. The vessels and their principal branches were constant \\ \er\ apparent. 



154 DISEASES OF THE CEREBRUM AND CEBEBELLUM. 

which may be obtained by the use of the compound jalap powder, followed by 
calomel carried almost to the point of salivation. This seems to me to be 
rather energetic treatment ; and I think that the purgative alone, with just 
sufficient calomel afterward to insure a continued free action of the bowels, 
ia ] inferable. For the purpose of diminishing vascular tension, either tartar 
emetic (F. 35), aconite, orveratrum viride (F. 36) may be used. Should 
the cerebritis be found to depend upon syphilis or lead, the iodide of potas- 
sium may be employed as the most serviceable remedy. Blood-letting is 
admissible in serious cases, and is recommended by nearly all of the older 
writers. The head may be shaved and blistered, or cauterized; but I am 
convinced that sub-occipital vesication is in every way as good, and the 
infliction of this punishment is not warranted. If there be any otitis, it 
is well to promote otorrhoca; or, if there be a collection of pus beneath a 
depressed and fractured bone, it may be liberated by a free incision. 



CHRONIC SOFTENING. 

Definition A disease of the brain of a very serious character, gene- 
rally of a secondary nature, and dependent upon impaired nutrition of the 
brain-substance through occlusion of the cerebral vessel, and symptom- 
atized by a numerous variety of mental, sensorial, and motorial symptoms. 
Much contusion has resulted from the use of a variety of terms, such as 
u red softening," "white softening," "inflammation of the brain," and 
other names which tend to mislead the student. For our purpose it will 
do to consider white and red softening as different stages of the same con- 
dition, which may result from a variety of causes ; and inflammation of the 
brain more as the condition which I have just described than that of which 
I propose to speak, viz., the variety spoken of by Reynolds and others as 
" non-inflammatory softening." 

Symptoms The symptoms of softening of the brain may follow a 

cerebral hemorrhage, embolism, or thrombosis, or perhaps be connected 
with symptoms of cerebral tumor; or, again, cerebritis may leave behind 
it a chronic condition expressed by the symptoms I am about to detail. 
The early troubles of the primary form are those of intelligence; the 
patient becomes silly, loses his memory of events which have recently 

transpired, is unable to concentrate his attention, and becomes restless and 
irritable, quarrelling with his immediate friends, and getting quite excited 
towards night. His speech may become affected, and he sits by himself 

for hours during the day, and mutters constantly a mass of disconnected 
rubbish. This condition of stupidity in creflpes ; tie may become drowsy 

and complain of headache, with feelings of head-pressure; he may tell us 

thai his limbs feel heavy, and complain of muscular pain, from which he 

suffers in the attempt to make any movement. As to other sensory dis- 
turbance, hyperesthesia is much more common than anaesthesia ; though 
cutaneous areas, in which Bensation is impaired, are by no means rare. 
Motorial troubles are of later appearance^gommencing with gradual loss 



CHRONIC SOFTENING. 155 

of power of an irregular character, which may affect either the arms or legs 
in the beginning, but finally becomes general. This paralysis is not always 
constant, there being a greater loss of power at times than a1 others. 
The first indication of the motorial trouble may appear either in tin- exe- 
cution of some ordinary act, which will be performed very clumsily; or in 
locomotion, when tin; patient will stumble or full to tin- ground, as there 
may be a sudden giving way at the knee. When Ik- walks be BCarcel) 
lifts his feet from the ground, but drags them after him in a helpless 
manner. With the paralysis there may be a certain amount of rigidity, 
or tonic spasms, affecting the muscles, so that there are occasionally spastic 

I contractions, which last for some little time. Epileptiform convulsions may 
occur during the disease, as well as attacks of mania, which arc quite vio- 
lent. When the softening is secondary, and follows an attack of embolism, 
thrombosis, or cerebral hemorrhage, the initial symptoms make their ap- 
pearance in from one to two weeks after the occurrence of the hemiplegia. 
The troubles of intelligence are those which first attract our attention, and 
are generally connected with high temperature and severe headache. The 
patient may become delirious ; lie indulges in delusions, and grows ab- 
normally sensitive; or, on the other hand, he is drowsy, stupid, and 
melancholic; and after this may follow paralytic contractures, clonic 
spasms, convulsions resembling epilepsy, or fibrillary contractions ; and he 
may finally become comatose. It is not uncommon for the patient to in- 
voluntarily pass his feces and urine. With the formation of cysts or ab- 
scesses, which constitute a late result of cerebral softening, convulsions of 
an epilcptoid character may make their appearance ; or, should the con- 

^dition be acute, and result from otitis, as is the case in cerebritis, these, 
as well as other symptoms, may be among the first to develop. Affections 
of speech are quite symptomatic of softening, because in so many of the 
cases the middle cerebral artery is that obstructed or destroyed. The 
hemiplegia, which may occur, is unattended by any loss of consciousness, 
and electro-muscular contractility is generally perfect or even exaggerated. 
The following may be presented as an illustrative case : — 

J. A., aged 45. The patient was brought to me by his wife during the 
summer of 1872. Four years before, while actively engaged in business 
which demanded the most devoted attention, and required a great deal of 
intellectual labor, he began to suffer from headaches limited to the frontal 
region. These were so severe that while engaged in his office he was 
obliged to bind a, wet towel about his head. He suffered very greatly 
from insomnia, and found it impossible to Bleep unless he took large doses 
of opium. He very often awoke in the night, and went upon the house- 
top or out into the street, wandering about the city until morning, lie 
became very moody, treated his wife with indifference, and scolded his 
children without cause. He could not talk for live minutes at a time 
without rising and pacing furiously about the room, while he seemed to 
be annoyed by the slightest noises about the house. The trickling of 
water from the pipe over the water-closet tank, which was next to his 
bedroom, so annoyed him that, in a lit of impatience and ungovernable 
irritability, he wanted to send for the plumber in the middle of tic 
night. His wife persuaded him to consult a homoeopathic physician, bv 



156 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

whom he was treated for nearly a year, and at the end of that time 
went abroad. He had meanwhile grown much worse, his mental state 
was much more aggravated, and his headaches, though not so severe, 
were still constantly present. He complained of formication of the soles 
of the feet, and liis walk was markedly affected, both feet being scarcely 
lifted from the ground, and he dragged one after the other when he 
walked. He lost rapidly in flesh, and though the sea-voyage did him some 
good, he relapsed into his previous state after he reached Europe. While in 
Switzerland he had an epileptiform attack, and after recovery found that his 
right side was paralyzed. Ilis speech was affected, and from what I can learn 
he must have been aphasic. The paralysis improved in a short time, and, 
strange to say, his mental condition also underwent a change for the better. 
After a few months he returned to New York, when I saw him. 

lie was then in an almost helpless condition, and needed the assistance 
of a cane and his nurse's arm to make any progress. He was bent over, 
and his chin was depressed, so that it almost touched the chest. The 
month was open, and the lower lip drooped slightly; while from the cor- 
ners of the mouth there was an escape of saliva which trickled down over 
his chin. His face bore a very vacant look, and when he attempted to 
speak it was clouded by an anxious and discontented expression, which 
arose probably from the vexation he felt at being unable to speak. Pho- 
nation was not affected, but word formation seemed entirely lost, so that 
hi- attempts to speak consisted in the production of disorderly noises, the 
tongue being used extensively, the lips not participating. He could not 
protrude his tongue when told to do so. His right pupil was larger than 
the left. Ilis right side was partially hemiplegic, and his wife stated 
that the loss of power was greater at times than at others. The right fore- 
arm was slightly flexed upon the arm, and the fingers seemed rigid. His 
control over the bladder was partially lost, and very often he would void 
his urine while upon the street, or at night. There is a history of trem- 
bling which affects the right arm and leg. This occurs during quiescence, 
and seems to have no connection with voluntary movements. His appe- 
tite is voracious, but there appears to be some difficulty in swallowing, so 
that it is found necessary to cut up his food. About two weeks ago he had 
a slight epileptoid attack. During warm days he seems disposed to Bleep 
a great deal; but when excited by the presence of -disagreeable people, or 
thwarted or crossed, he becomes extremely violent, and even dangerous. 
I saw him but once, and I believe he was afterwards sent to an asylum. 

Causes V'wM and foremost are primary forms of disease, which either 

produce occlusion of an artery, or irritation from a blood-clot or tumor. 
Vascular degeneration, which may result from general disease, or renal 
trouble, acts as a predisposing Cause in the development of cerebral soften- 
ing. Intellectual fatigue, sexual excitement, alcoholic intoxication, head 
injuries, and local disease act as exciting causes. Exposure to cold has 

been given as a Cause Of cerebral Softening, and exposure to the direct rays 

of ili«' -mi may induce the condition. Bamberger 1 has observed it as a 
consequence of typhus and acute articular rheumatism ; and Jaccoud 9 con- 

1 Beobachtungen mid Bernerkungen liber Hirnkrankheiten (Wttrzburg Ver- 
handlungen, 188 * 

Pathologic Interne, ten), i. p. 1 77. ^ 






CHRONIC SOFTENING. 157 

aiders that it may be produced by syphilis in two different ways, either by 
a gummy tumor, which gives rise to irritation of the tissue in the neigh- 
borhood, or by infiltration. 

Cerebral softening is more common among people of advanced life as an 

idiopathic affection, and unless it follows embolism injuries, or like causes, 
is quite rare in early life, Andral having found only :V.) cases out of 1 53 
in persons under 40. Jaccoud is of the opinion, which others hold, that 
males are more commonly affected than females. Season has nothing to 
do with its development. 

Morbid Anatomy and Pathology There has beeu great dif- 
ference of opinion in regard to the pathology of brain softening. Those 
who described it in the early part of the century considered it to be an in- 
flammatory affection, while Kostan,' who reported many cases, recognized 
a non-inflammatory form which he had met with among old people with 
rigid arteries. As Russell Reynolds 8 very properly observes, " much con- 
fusion has arisen from a tendency to misinterpret morbid anatomical ap- 
pearances, without paying sufficient attention to their mode of origin." 
Cruveilhier 3 considered two forms, one of which was apoplectic, or " apo- 
plexie capillaire," which he did not consider inflammatory ; and. later, 
Andral 4 announced his disbelief in the necessarily inflammatory origin of 
the disease, and considered it due to occluded arteries and insufficient 
nutrition. Among the powerful advocates of the inflammation theory are 
Durand-Fardel 5 and Gluge, 6 while upon the other side may be mentioned 
such additional names as Kirkes." Laborde, 8 Hughlings Jackson. 9 and 
many others. It maybe said, 1 think, that softening of the brain is nearly 
always of an inflammatory character when it follows head injury and dis- 
ease- of the cranial bone, while the majority of cases, which are secondary 
to occlusion of vessels, are dependent upon general disease of a non-inflam- 
matory nature. 

If the disease be primary, Jaccoud considers that the lesion will be of 
the first form, that is, at a single point; but that when the softening follows 
typhus fever, puerperal, and other general diseases, the foyers will be mul- 
tiple. If the softening results from embolism or thrombosis, or. in tact. 
from any other condition producing obstruction of the circulation, there 
will first be a congestion with exudation of serum, hyperemia of the vessels, 
and perhaps capillary hemorrhage, which is attended by coloration of the 
part- in the neighborhood, so that they become of a bright pink or red 
color, and are limited by other regions, which are anaemic ami blanched, 
ami a condition which has been called " red softening" exists. If this 
morbid process takes place in the gray matter, the hemorrhagic spot will 
he of a much darker color, and much more sharply circumscribed. The 



1 Recherches sur le Ramollissement d'u Cerveau, 1820. 

System of Medicine, vol. ii. p. 161. ; Etude de la M6d., etc. . 1821. 
1 FVecis d'Anatomie Path., 1829. ' Traite du Ramollissement, 1848. 

b Comptes Rendus, 1837. " Op. cit., vol. ww. p. B21. 

1 Le Ram. et la Cong. <lu Cerveau, Paris. 1859. 
,J Op. cit. 



158 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



next change takes place within a week or two, when the color of the lesion 
becomes much mere pale, and the exudation granular; fatty degeneration 
takes place, the softened spot becomes extended, the neuroglia-cells, nerve- 
fibres, and nerve-cells become disintegrated, the axis cylinders disappear, 



Fig. 16. 
Diagrammatic. 




D 



Tissue Changes in Soften in< 



A. Vessel. B, B, C. Nerve-tubes. 
E. Swollen uerve-tube. 



D. G luge's corpuscles. 



and the bloodvessels alone may be distinguished, and even they are greatly 
disorganized. At this stage the softened spot becomes much paler, is 
creamy in consistence, and contains stringy flakes of a fibrinous nature. 
It is extremely rare for resolution to take place even in the earliest stage 1 . 
A form of softening, alluded to by Jaccoud, Durand-Fardel, and others, 
consists in tin- formation of yellow plates, chiefly in the convolutions 
(plaques jaunes) which are the result of a partial metamorphosis of the 
softened patches. There may be also a, retrograde change, as is witnessed 
in the formation of cysts, which are filled by a chalky fluid containing fat 
globules. There is always present a variety of cells known as Gluge's 
globules, which are composed of collections of small granular bodies, some- 
times Burrounded by a cell wall, and these are produced by the degenera- 
tion of neuroglia-cells, the debris of which are aggregated as masses of fatty 
granules. These little bodies, which rarely exceed ^J^ of an inch in 
diameter, have been found by Reynolds, Turck, and Bouchard in the cord, 

where their form of origin is the same. 

The various colors may be seen in the brain at the same time, patches 
of red. brown, yellow, or white denoting ditferent stages of the morbid 
process. The lighter shades generally indicate advanced stages, such 

being the opinion of Durand-Fardel. Charcot and various observers have 

found form- of White softening in old people; and others, among them 

Cotard, Prevost, Bastian, and Reynolds, have seen cases of the same kind. 
It i- extremely doubtful whether the coalition of degeneration was not 



CHRONIC SOFTENING. 159 

preceded by some exudation of blood-elements, and, if it was not, whether 
the condition had not been confounded with sclerosis. Softened patches 
may be in the second stage removed by allowing a stream of water to fall 
upon the cut surface, and when the disorganized tissue is washed away a 
depression is left. If the cut be made through a brain which presents the 
appearance of red softening, the affected patch will be found to stand 
slightly above the normal tissue, and this is probably due to a hyperemia 
of the capillaries of the part. This fulness of the capillaries is undoubtedly 
due to collateral circulation of blood through the vessels contiguous to that 
obliterated, the normal functions being increased through double duty 
imposed upon them. This is the view held by Weber, 1 as well as by PreVost 
and Cotard. 2 

If the yellow appearance of the softened patches be not due to altered 
coloring matter of the blood such as we find in the early stages, it may be 
found later in connection with gelatinous circumscribed masses scattered 
through the brain or about old clots or tumors. 

The parts most liable to this change are the corpora striata, optic thalami, 
white substance of the hemispheres, and sometimes the cerebellum; or 
there may be multiple foyers scattered through different parts of the 
brain. 

Durand-Fardel 3 has collected sixty-two cases from the writings of other 
authors, in which the locality of the softening was the following : — 

Convolutions and white substance . . . . . .22 

Convolutions alone ......... 6 

White substance alone ........ 5 

Corpus striatum and optic thalamus ...... 6 

Corpus striatum alone . . . . . . . .11 

Optic thalamus alone ......... 4 

Pons Varolii .......... 3 

Crus cerebri ......... .1 

Corpus callosum ......... 1 

AValls of the ventricles (septum) ...... 1 

Fornix ........... 1 

Cerebellum ........... 1 



Diagnosis. — In an excellent lecture delivered by Hughlings Jackson, 4 

he says : •• I do not see how the diagnosis that there is actual softening of the 
brain is in any case to be possibly arrived at. unless the patient has certain 
local paralytic symptoms, as hemiplegia, or some other symptoms imply- 
ing a local cerebral lesion, such (ts affection of speech ; or. again, unless 
there be signs of cerebral tumor (severe headache, urgent vomiting, and 
double optic neuritis) or evidence of injury to the head. For. >o far a- I 
know, cerebral softening is always local ; I know nothing of general or 
universal softening of the brain. To be warranted in diagnosing soften- 



1 llandbuch <ler Allgem. untl Spec. Cliinir.. 1865. 

2 Gaz. Med. de Paris, Mai l!>, 1866, p. S36. 

: ' Op. cit. ' London Lancet, Sept. i. 1875 



160 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

ing, you must have symptoms which point to local disease. I do not say 
that Local cerebral softening cannot exist without localizing symptoms. I 
only say that in their absence you are not warranted in diagnosing its 
existence." This remark is made in connection with the lecturer's disbe- 
lief in various forms of functional disease which are so often improperly 
called " softening," and in which a few functional symptoms which disap- 
pear under appropriate treatment are vested by the careless or unscrupu- 
lous practitioner with an importance they do not deserve. These symptoms 
are those which follow depraved states dependent upon venereal excesses, 
fright, and other causes which lower the tone of the nervous system. 
Jackson's warning is a pertinent one. 

If we have hemiplegia, some renal or cardiac disease, and valvular de- 
posits, with murmurs, our suspicions of softening generally turn out to be 
well founded. The history of the antecedent attack, should it be throm- 
bosis, embolism, or cerebral hemorrhage, has much to do with the making 
of a correct diagnosis. As 1 have said, hemiplegia, unattended by loss of 
consciousness at the outset, is a diagnostic point in favor of softening, and 
suggests embolism, and if the train of symptoms given on a previous page 
is afterwards expressed, there can be little doubt as to the nature of the 
disease. A point insisted upon by Jackson is that the general mental 
symptoms of softening are either expressed before the softening, or follow 
it. lie denies that general mental symptoms (wandering, delusions, etc.) 
are directly caused by the softening, but that special mental symptoms 
(affection of speech) are. The general mental symptoms follow a few 
hours or days after the local softening. The " preceding mental symp- 
toms" are irritability and altered disposition. 

Chronic meningitis may resemble cerebral softening, but in the former 
the pain is more diffused, and the motorial phenomena (spasms, etc.) are 
more pronounced. Softening with tumor may be made out from the addi- 
tional presence of optic neuritis, choked disk, and vomiting. Some forms 
of progressive meningitis, such as pachymeningitis with cerebral hematoma 
(vide the case detailed in the chapter upon pachymeningitis), may closelj 
simulate cerebral softening, and very often the diagnosis is exceedingly 
difficult, or may be impossible. The symptoms of hemorrhage from rup- 
ture of a meningeal vessel, such as occurs in the course of these chronic 
varieties of meningitis, may closely counterfeit the apoplectic attack which 

occurs so often in cerebral softening. 

Prognosis Cerebral softening is one of the most unfavorable con- 
dition- with which we are acquainted. Death follows the establishment 
of i he morbid condition sooner or later in nearly all cases occurring in 
adull life. An occasional case of recovery may be encountered in a young 
Subject, luit this is exceptional. Of 1<»!) eases of both forms of cerebritis 
Collected 0] Aitkin. 1 he found that the duration of life in cases of this 
disease Was the following, which also proves that there are more cases of 
the acute than the clironie form of the disease. 



1 The Science and Practice of Mtdicine, vol. ii. ]>. 304. 











APHASIA. 










1 died in 


12 hours. 


2 


lied 


in 12 c 


ays. 


1 ( 


lied in 


35 


days. 


1 " " 


15 


< t 


3 


i i 


" 13 


" 


1 


(( t< 


36 


•• 


1 " " 


24 


ti 


3 


(c 


" 15 


(< 


1 


11 (i 


47 




1 " " 


32 


a 


1 


u 


" 16 


" 


1 


(( a 


4 9 


n 


5 " " 


2 


lays. 


2 


" 


" 17 


" 


1 


" " 


60 


a 


9 " " 


3 


1 1 


4 


" 


"18 


u 


1 


(( (i 


65 


ii 


5 " " 


4 


i > 


5 


(i 


ii 20 


ti 


1 


a it 


68 


it 


4 (i x 


5 


" 


3 


(( 


11 21 


a 


1 


(I if 


190 


tt 


7 " " 


6 


a 


1 


" 


" 22 


" 


1 


if (I 


2-20 


" 


8 " " 


7 


" 


1 


" 


" 23 


If 


1 


if ft 


5 


months 


8 " " 


8 


i i 


1 


u 


" 25 


" 


2 


ft ti 


6 


" 


3 " " 


9 


(( 


1 


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ii ti 


1 


ycai-. 


g a « 


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4 


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" 30 


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ii ii 


3 


year-. 


4 «« ii 


11 


" 



















101 



The greater number of these patients died, it will be seen, before the 
twelfth day. 

The experience of other observers is slightly different from this. as many 
persons with secondary softening have been found to live for years after 
the commencement of the softening. These cases being all fatal we have 
to remember as well that there are many instances in which the abscess 
becomes encysted, or the non-inflammatory softening circumscribed. 

Treatment Our efforts should be to improve, as rapidly and fully 

as possible, the patient's general condition. For this purpose we must 
not only prescribe for him a hearty hydrocarbonaceous diet, but we are to 
insist upon cold bathing, out-door exercise, and moderate stimulation. 
As medicaments, I am positive that there is no better remedy than phos- 
phorus, which may be given in combination with cod-liver oil, or in solu- 
tion in absolute alcohol (FF. 37, 24, 25, 2G). The bromides may be 
given in combination with lupulin (F. 88), if there be headache or de- 
lirium; or cannabis indica, as recommended by Reynolds (F. 39). If 
the bowels be sluggish, a free use of the saline cathartics is of great bene- 
fit; and to relieve the head symptoms, leeching may do much good. In 
the chronic form tonics are indicated, and for this purpose I prefer the 
ammonio-citrate of iron (F. 40). I am not in favor of strychnine, and 
should hesitate to use it if the case were at all acute. 



ASEMASIA 1 (APHASIA). 

Synonyms Aphemia, Alalia. Lalpplegia, Paralalie, Agraphia. 

Definition — We may define asynesis, or aphasia (which is derived 



1 It has occurred to me thai the word "aphasia," as at present used, has too 
restricted a meaning to express the various forms of trouble of this nature, which 
not only consist of speech defects, bul loss of gesticulating power, singing, read- 
iting, and other functions by which the individual is enabled to put turn- 



ing, wi 



Belf In communication with his fellows. I would, therefore, suggest "asemaaia" 
a< a substitute for "aphasia." The word is derived from & and nmuiu fan 

inability to indicate by signs or langUtl 
11 



162 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

from the Greek a, priv., and $a'<H$, speech) as a partial or complete loss 
of speech, which does not depend upon any vocal or lingual impairment 
of function, but upon disease of the speech-centre, whereby the origina- 
tion of forms of expression is suspended or deranged to a greater or less 
degree, or a kindred loss of writing or gesticulating power. Aphasia 
must not be confounded with aphonia, or with the condition met with in 
idiots or mutes. The disease we are about to consider is seated, as it is 
generally conceded, in the third frontal convolution, and is characterized 
by the disruption of the connection between the formation of ideas and 
their expression by the lingual apparatus; or, as Broca has expressed it: 
"Le mot aphasie sert aujourd'hui a designer la perte ou la perversion de 
la faculte du langage ; en generale e'est de cette faculty que nous permet 
d'etablir une relation constante entre une ide*e et un signe, que ce signe 
soit un mot, un geste, ou un trace quelconque." This loss of function varies 
from temporary trouble, such as the substitution of an occasional wrong 
word, to a condition of decided intellectual abasement. It will be well, 
before discussing the subject further, to say a few words in regard to the 
history of this interesting disease. Our first information comes from very 
early writers, among whom were Sextus Empiricus, 1 who lived two hun- 
dred years before Christ, and Pliny. Trousseau (p. 253) quotes the latter: 
" Illness, falls, a mere fright, impair it (memory) partially, or destroy it 
completely. A man struck by a stone forgot the letters of the alphabet," 
etc. Later, Sauvage, 2 Cullen, 3 and the two Franks 4 wrote most ex- 
haustively during the seventeenth and eighteenth centuries, but all of 
these authors devoted more attention to mutism, aphonia, and like condi- 
tions, than to aphasia. In 1840, Lordat, 5 who, strange to say, became 
aphasie himself, described the disease under the name of alalia, a term 
used by Jaccoud at the present day. Though Gall, 6 as early as 1808, 
localized the speech-centre above the orbits, it was not till l<s2o that its 
pathology and morbid anatomy were clearly settled by Bouillaud, 7 who, 
working upon Gall's theory, enunciated the doctrine that "the anterior 
lobes of the brain are the organs for the formation and recollection of 
woids, or the principal signs which represent our ideas." 

Afterwards, Bouillaud's views were nevertheless opposed by Andral, 8 Cru- 
veilhier, 9 and others, to whom I shall hereafter allude. Experiments made 
by Marce in 1856, and by others, confirmed all that Bouillaud had stated. 



1 Translated by Iluart, Amsterdam, 1725, p. 98. 

2 Nosologia Meth., Paris, 1722, t. ii., class (i, p. 249. 

3 Synopsis Nosologies Meth., edited by Frank, 1787. 

4 De Curandis Horn., Mannheim et Vienna, 1792-1821. 

8 Analyse de la parole pour servir a la theorie du divers cas d'alalie et de para- 
lalia «•!<•.. Montpellier, 1848. 

■ Sur let Fonctiona tin Cerveau, Paris, 1 825, t. v. 

7 Treatise on Encephalitis, p. 284. 

8 Maiadies de l'Encephale (Clin. Med., 1634, t. ii.). 

■ Sur Le principe legislateur de la parole (Bull, de 1' Academic, 1839). 



aphasia. 103 

The next step was taken by Marc Dax 1 in 1836, and by his sou, who con- 
firmed his observations in 1863. It was the younger Dax who demon- 
strated that aphasia was connected with right-sided paralysis. 9 Broca' 
next limited the spot to the second or third frontal convolution. Since 
then Hughlings Jackson, 4 Jaccoud, Trousseau, 6 Dieulafoy,' Gairdner,' 
and many others have added much to the interest of the subject. There 
has been considerable discussion as to the proper name for the affection. 
Lordat, to whom 1 have already alluded, preferred the term " alalia f* 
and others, among them Broca, denominated the condition "aphemia." 
The word is still used by some writers; but the word "aphasia" has 
come into general use, and is generally conceded to be much more expres- 
sive and proper than any other. 

Jaccoud, who has rather added to the confusing nomenclature, presents 
a table, which embodies nothing new, and, if anything, increases the in- 
definiteness of our knowledge of the disease. Aphasia, or asemasia, is 
most protean, as it may involve the power of reading aloud, speaking* 
writing, and gesticulating, in part or together, in a number of curious 
ways. Let us then consider the phenomena which mark its existence. 

Speech The vocabulary of the aphasic patient is generally of the most 

limited kind, and in the beginning, should the condition follow a cerebral 
accident of any magnitude, his power of speech is totally absent. After ;v 
while he maybe able to command one or two short phrases, or such words 
as "yes" or " no" in reply to every question that may be asked. These 
words, or such as have become automatic from constant use, are employed, 
and it is very curious sometimes to hear the patient give utterance to m me 
phrase which, during health, he has constantly and sometimes uncon- 
sciously made use of. In other instances several words may be joined 
together in an incongruous manner; for example, it was observed, in a 
case I detailed when speaking of cerebral thrombosis, that the patient replied 
" When Benny" to the question " where do you live?" 9 Durand-Fardel 

1 Lesions de la moitie gauche de I'encephale coincidant avec l'oubli dea signes 
de la pensee. Mem. lu au Congres Medicale de Montpellier, 1836 — Gaz. Bleb. 
Avril, 1865. 

2 Sur le siege de la faculte du langage, etc. (Bull, de la Soc. Anat., 2e Serie, 
t. iv. 1861). 

3 Gaz. Heb., April 28, 1865. 

4 Rep. London Hospital, vol. i. 1864, p. 388. 

5 Gaz. Heb., July and Aug. 1864. 

6 Clin. Med. de I'Hdtel Dieu, t. ii. p. 571. 

7 Gaz. des Hop., June, L865. 

8 Arch, de Med., t. ii. pp. 189-314, 1869. The reader is referred to the ad- 
mirable thesis of Legroux, Paris, 1875 (A. Delahaye), for a most complete bib- 
liography of the subject. 

9 Numerous interesting cases are reported. One described by Osborn* is illus- 
trative <>f a form which is sometimes met with. The patient comprehended written 
language, and expressed himself in writing, only occasionally transposing words. 



* Forbes Winslow, Obscure Diseases of the Mind. p. 843. 



164 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

alludes to a patient who always gave the following absurd answer : 
tk Madame etc. mon Dieu, est-il possible, bon jour, madame." Legroux 1 
remarks in regard to these forms: " It is to be supposed in these cases 
that the patients speak without hearing what they say, or that their audi- 
tory receptivity is unable to reveal the imperfection of their speech." 
( Occasionally, however, the aphasic is conscious of the absurdity of his 
reply ; he will laugh in a silly manner, or appear annoyed or worried, for, 
in a majority of cases, there is perfect mental integrity, and the position 
of the patient is very like that of a man driving a runaway. horse. It has 
often reminded me of a condition which I have more than once expe- 
rienced myself, and which is by no means uncommon. I allude to 
the state of the mind during nightmare. When the individual is about 
to awake he is semi-conscious of the unsubstantial character of the im- 
pending danger of the dream, but cannot save himself and cannot awake. 
During the nightmare a patient may actually spring from the bed, or 
make some other voluntary attempt to escape. Lordat, who was aphasic, 
gave, after his recovery, an account of the inward sensations which he felt 
during his illness, and which perfectly indicate the part played by memory. 
He could think, he could coordinate a lecture, or change its arrangement 
in his own mind, but he was unable, although he was not paralyzed, to 
express his thoughts in speaking or writing. " I thought," said he, " of 
the Christian doxology, ' Glory be to the Father, the Son, and the Holy 
Ghost,' and I was not able to recollect a single ivord of it. Thoughts 
seemed to arise freely, but the mode of expressing them in sounds, the 
receptacle of these thoughts, was forgotten."' 2 The words which are gene- 
rally lost, and are the latest to be acquired, are the pronouns and substan- 
tives, while those which the individual retains the power of articulating 
more than any other are the interjections, such as " Oh I" "oh, dear!" "ah, 
yes!" It is not rare for patients to exhibit two other peculiarities; one is 
a substitution of other words for those intended, the second is a conjunc- 
tion of incongruous syllables ; for instance, a patient may say " bel-eb" 
for "belief," or, as in the case reported by Trousseau, " bon-tif " was sub- 
stituted for kk bonsoir." Some persons are able to repeat words which are 
first pronounced for them by another, but are unable a minute afterwards 

He could translate fluently, and was able to calculate arithmetical sums. He 
could not pronounce the letters "&, q } w, y, n\ .<■. and :," and the letter "t" 
seemed to puzzle him. Dr. Osborn requested him to read the following sentence 
from the By-Laws of the College of Physicians: " It shall be in the power of the 
college to examine or uol any Licentiate previous to his admission toa fellowship, 
ae they shall think lit." The resull was as follows: "An the bi what in the 
temother of the tro tho todoo to majorum or that emidrate ein einkrastrai mes- 
treil toketra to torn breidei to ra fromtreido as thai kekritest." It is rare, how- 
ever, for a patienl to accomplish as much as this. He generally becomes im- 
patient, and gives up the at tempi after half a dozen imperfeel words. 

1 De I* Apli.l-ie. p. I 5. 

2 TrOUSSeau'fl Lectures on Clinical Mediciifc, \ol. ii. p. '2i:\. last Am. edition. 

is;::. 



APHASIA. 1G5 

to articulate the desired word. A patient of* my own, when requested to 
tell what it was he held in his hand, could not say. When asked if it was 
a paper, he shook his head ; an apple? another shake, and a shrug of the 
shoulder; a cane? a pitying smile, and a gesture of impatience ; a book ? 
a bright smile, and the immediate articulation of the word "book." 
"What did you say it was ?" To which there was a, puzzled look, an 
attempt to speak, and no answer. Jackson and Others have alluded to 
striking examples of this defect. Bastian 1 alludes to a form in which 
there was transposition of the letters, the patient Baying "gum" for 
" mug." Patients are very apt to substitute words. Thus, when one 
was asked if he wanted to sit down, replied: "Give me a bottle, I 
want to rise down." Baudny 2 alludes to a case where the connection was 
better shown. The man asked for a " cup of cow!" Sonic aphasics, 
though they may be utterly unable to speak, can sing. Hughlings Jack- 
son 3 alludes to two aphasics, boys, one eight and the other ten, who could 
sing. Bacon reported the case of an idiot hoy who was aphasic, hut could 
sing quite cleverly. These cases are very rare, but interesting examples 
are occasionally brought forward. Behier reports the case of a sailor who 
could sing the Marseillaise, using the word " tan" throughout. 

Writing The aphasic individual who cannot speak is occasionally 

able to write, but, in my experience, I have generally found the loss of 
these faculties (speech and writing power) to coexist. This variety, 
which has been called agraphia by Ogle, has been divided by him into 
the anemonemic and atactic varieties. We may meet with the same 
peculiarities which attend the form I have already alluded to, viz. : sub- 
stitution of words or letters. The patient may be able to write after a 
copy, but this is rare. lie takes his pen and begins quite confidently, but 
as soon as the pen touches the paper he makes a series of scrawls, which 
rarely bear any resemblance to the letters forming the words he is required 
to write. 

Bourneville 4 relates a case : "A woman named Justine Thomas entered 
the hospital La Pitie December 15, 1870, and was assigned to the service 
of Marotte. She became hemiplegic on the right side, and had complete 
aphasia. On the 18th of December the hemiplegia had nearly disap- 
peared, but the aphasia persisted. At this time she was asked to write 
her name, and only succeeded in producing the appearance presented in the 
accompanying cut (Fig. 17, A). At different times during the year speci- 
mens of her handwriting were taken, which showed progress and marked 
improvement, the last attempt being made in November, L871. (Fig. 

17,7?.) This lost power must not be confounded with Other conditions 
symptomatic of insanity or sclerosis and the element of paralysis, which 
should be taken into account if there be any suspicion of a LOSS of muscu- 
lar power. A hemiplegic may be unable to write simply through muscular 
weakness and difficult muscular c< ordination. Of C0UT86 time will ena- 



1 Med.-Chir. Rev., xliii. p. 209. 2 Diseases of Nervous System, p. 412. 
3 Lancet, 1871, p. 430. 4 Legroux's Thesis. 



1GG 



DISEASES OF THE CEREBRUM AND CEREBELLUM 



blc us to sec whether the inability to write is due to this cause, or is really 
the "agraphic" condition. Reading, singing, and the power of gesticu- 



Fi<r. 17. 




lating are loit cither separately or together. A person who cannot speak 
is sometimes able to sing. So, too, in reading. He may read mechani- 

Fig. 18. 



/ t %- % 


f? 




*\_ 


/ 




rjk_ 


uy^-r^ 






<£? 




<^ is 






B J^<i4i>$-fk 


w 


£'& 


n 



Handwriting of two patients; "A" being affected with agraphia, and "B" with cerebro- 
■piaal sclerosis. The first specimen Is intended for " Possible to see you on Tuesday." Tbe 
second, " Dieu «'t mon Droit." 

cally without appreciating the sense, or may drop liis words or substitute 
others, and perhaps is unconscious of liis mistake. He may be unable to 
read, bul may show by signs that he knows what such and such a picture 
ma) h<«. The power of gesticulation may be, and often is, losi. He may 
make attempts t<> describe the figure of some object, bul cannot do so. 
Trousseau related the case of a person who was told to imitate the playing 
of a clarionet, bul when he attempted to do so beat instead an imaginary 
tambourine. Il< \% sometimes able to count figures which arc before him, 
nv pieces of monej put in his hand, but if he has no such reminders, and 

ifl limply told tO count, he may he able to count up to a certain number, 

and Bay ten, and docs so in a peculiarly automatic way. After this, when 
•ome though! in required to make combinations, the effort is unsuccessful. 



APHASIA. 1CT 

For the purpose of making himself understood it is necessary that an 
individual should he familiar with signs (visual and auditory), which have 
been received either upon the retina or tympanum, and reflected upon 
certain ideational and receptive centres, where they are retained and 
serve as models for expressions the individual may wish to make in the 
future. The mental process which attends the formation of language or the 
communicating faculty becomes so intricate and automatic thai insensibly 
the process of comparison and centre stimulation goes on without the 
knowledge of the person, and words and signs are made upon the ground- 
work of impressions previously received for guidance and formation. It 
is only when disease affects the particular centre that the harmony is lost, 
and the patient, though possessing the ear and eye as mentors, is unable 
to coordinate the mental factors of intelligible communication. The fa- 
cility for connecting ideas with sounds or signs, which is a normal faculty, 
is thus spoken of by Ogle : " This faculty of converting ideas into symbols 
is quite distinct from that of converting symbols into ideas. The one may 
be acquired or lost independently of the other. Thus, a child Learns to 
interpret the language of others before it can itself speak. Adults, as a 
rule, follow the same order in learning a new or foreign language. Most 
of us, moreover, know what it is to have the pictured map of some familiar 
object in our minds, yet to be perfectly unable to call up its name." This 
defect depends not upon the apparatus for the receipt of impressions, nor 
upon the apparatus for communication, but upon a loss of function in what 
has been called the "central organ of articulate speech; and both the ina- 
bility to remember words and connect them with ideas, and the inability 
to compel the organ of articulation to form words,' depend upon some 
change at this point. The loss of power to express ideas is symptomatized 
by aphasia, agraphia, or other defects in the communicating faculty. If 
there be amnesia, the central disturbance (whatever it is) is the same, 
and the variation of lost means for expression depends on the manner 
of separation of organs from mental control. There seems to be little 
doubt as to the seat of this centre, and as to the circumstances under which 
it is impaired. The collected cases of different authors mainly go to show 
that the left side of the brain is the seat of a lesion in its anterior part, and 
that the third frontal convolution is the one most constantly involved. I 
have already casually referred to Broca's investigations, and will now- 
present his description, which has been modified by Bateman, 1 of its anato- 
mical seat. "The anterior lobes of the brain comprehend all thai part of 
the hemisphere situated above the fissure of Sylvius, which separates it 
from the temporo-sphenoidal lobe and in front of the furrow of Rolando 

(1\. \\.) which separates it from the parietal lobe The direction of 

this furrow is almost transverse; setting out from the median line, it con- 
tinues almost in a direct line', and after describing some Mexuosities ter- 
minates below and outside of the fissure of Sylvius, which it meets almost 
at a right angle behind the posterior border of the lobe of the insula. 



1 Journal of Mental Science. 



168 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



'•The anterior lobe of the brain is composed of two divisions, the one 
interior, or orbital, formed by the several convolutions called orbital, which 
lie on the roof of the orbit, and of which I shall not have to speak; the 
other, superior, situated under the outer wall of the frontal bone, and under 

Fie. 19. 




the most anterior portion of the parietal. This superior division is com- 
posed of tour fundamental convolutions called, properly speaking, the fron- 
tal roiirttl nt ions; one is posterior, the others are anterior. The posterior, 
FF, slightly tortuous from the anterior boundary of the furrow of Rolando. 
It is therefore almost transverse, and ascends from without, inwards, from 
the fissure of Sylvius to the great median fissure, which receives the falx 
cerebri of the brain. This is why it (F F) is described indifferently under 
the name frontal, posterior, transverse, or ascending convolution. The 
other three convolutions of the superior* division are very tortuous and very 
complicated, and some practice is needed to distinguish them in all their 
Length without confounding the fundamental furrows which separate them 
with the secondary fuiTOWS which separate the second order folds, and which 
vary in different individuals according to the degree of complication ; that 
ie to say, according to the degree of development of the fundamental con- 
volutions. These three fundamental convolutions, 1,2, '■'>. are antero-pos- 
terior, and, running side by side, extend from before backward over the 
whole length of the frontal lobe. They comnu nee on a level with the 
superciliary arch, whence they are reflected, to be continuous with convo- 
lutions of the inferior division, and terminate behind in the frontal trans- 
verse convolution, F, F, which all the three enter. They are Called first 
( 1 ). second (2), and third (8), frontal convolutions. They may also be 
called interim! \ 1 i, middle (2), and external (3) ; but the ordinary names 
have prevailed. The firef (1) runs along the great fissure of the brain; 

ii presents, constantly, in the human species an anterio-posterior furrow 

more or less complete, which divides it into two folds of a second order ; it 



APHASIA. 169 

has, therefore, been divided into two con volutions, but comparative anatomy 
shows that these two folds form only a single fundamental convolution. 
The second (2) frontal convolution presents nothing peculiar; not so with 
the third (3), which is more external. The latter presents a superior or 
internal border, adjoining the tortuous border of the middle convolution 
(2), and an inferior or exterior border, the relations of which difte? accord- 
ing as they are examined before or behind. In its anterior half this bor- 
der is in contaet with the external border of the most external orbital con- 
volution. In its posterior half, on the contrary, it is free and separated 
from the temporal sphenoidal lobe by the fissure of Sylvius, S, S, of which 
it forms the superior border. It is in consequence of this latter relation 
that the third frontal convolution is sometimes called the superior margi- 
nal convolution. 

" Let me add, that the inferior border of the fissure of Sylvius (S, S) is 
formed by the superior convolution of the temporo-sphenoidal lobe, which 
is therefore called the inferior marginal convolution T, T. It is an antero- 
posterior fold, thin, and almost rectilinear, which is separated from the 
temporo-sphenoidal convolution T 2, T 2, by a furrow parallel to the fis- 
sure of Sylvius. This furrow is described under the name of the parallel 
fissure (with reference to the fissure of Sylvius, S, S). Lastly, when tin- 
two marginal convolutions, superior, 3, 3, 3, and inferior, T, T, are drawn 
away from the fissure of Sylvius, S, S, there appears an enlarged and 
slightly prominent eminence, I, from the summit of which five small sim- 
ple convolutions, or rather five straight folds, radiate in a fan-like manner. 
It is the lobe of the insula which covers the extra-ventricular nucleus of 
the corpus striatum, and which, arising from the bottom of the fissure of 
Sylvius, S, S, is found to be structurally continuous by its cortical layer 
with the deepest or most deeply seated part of the two marginal convolu- 
tions, 3, 3, 3, and T, T, and by its medullary layer with the extra- ven- 
tricular layer of the corpus striatum. The result of these structural rela- 
tions is, that a lesion which propagates itself continuously from the frontal 
lobe to the temporo-sphenoidal lobe, or, vice versa, will pass almost 
necessarily by the lobe of the insula, and that from thence it will mos1 
probably extend to the extra-ventricular nucleus of the corpus striatum, 
since the proper substance of the insula 1, which separates the nucleus 
from the surface of the brain, forms only a very thin layer." 

Not only may a lesion of the speech-centre itself produce aphasia, but 
in numerous instances (some of which have been referred to by Jackson) 
it may follow the destruction of adjacent parts, as a consequence of some 
such accident as the plugging up of the middle cerebral artery. As a 
consequence of such a pathological condition, a large area of brain sub- 
stance will be destroyed, so that impaired mental function as well as 
aphasia takes place. 

An important subject in this connection is the side o\' the brain which 
is affected. Though exceptional cases have been reported in which the 
right cerebral hemisphere has been the Beat of the lesion, the rule is the 
other way. In some instance.-, even, no lesion whatever ha- been found; 



no 



DISEASES OF THE CEREBRUM AND CEREBELLUM, 



or. on the other hand, the left anterior convolutions have been the seat of 
morbid change, and no loss of speech has been occasioned. Simpson 1 has 
related one ease where marked destruction of the left anterior lobe was 
observed, and yet no aphasia existed. This man, aged 65, who had been 
epileptic for ten years, having as many as three or four attacks a month, 
died. The white and gray matter of the left hemisphere were markedly 
atrophied, and there was a cavity in the left posterior frontal convolution 
1| inches longitudinally, and 1^ transversely. 

The following ease is interesting, as it shows that almost complete 
aphasia may exist without any disease of the island of Reil : — 

M. A. B., aged thirty-five years, married. Family and previous per- 
sonal history good, but it is possible to trace syphilis. The patient had an 
apoplectic attack in August, 1859, with loss of consciousness, which lasted 
for two hours ; on recovery it was found that she was unable to speak, but 
there was slight improvement after a few months. Present condition, 
July 17, 1874 : The patient is a medium-sized woman of seemingly good 
condition, with the exception of her nervous trouble. There is slight 
paralysis of the left side ; can move left arm well, but. slowly, and walks 
with a shuffling gait. Tactile sensibility, and sensibility to differences in 
temperature, are decidedly impaired on the left side, on which side there is 
an appreciable amount of analgesia. She protrudes her tongue in a straight 
line, but feebly. No loss of taste or smell. Her mental condition is be- 
low the average. This first part of her history I have taken from tin* 
records of the Epileptic and Paralytic Hospital, and I also find that for 
some months she has been suffering from symptoms of phthisis. When I 
saw her on August 10, 1875, the patient was in advanced phthisis; her 
nervous condition was the following : Paralysis of the left side; her left 
hand lies in her lap, the thumb being contracted and flexed ; the flexor 
tendons of the hand are rigidly contracted, so that at the wrists they stand 
out like tense cords. There is very little atrophy of the left upper ex- 
tremity, but there is a certain stiffness about the elbow-joints of this side. 
The left lower extremity seems to be nearly as strong as its fellow. Motion 
at the hip- and knee-joints is limited. She can raise her foot from the ground 
when sitting, but when she walks it is in a shambling manner, dragging 
her left foot, or scarcely lifting it from the ground. There is some para- 
lysis of the left side of the face, and it is impossible for her to protrude her 
tongue. Sensibility seems to he very slightly affected in the paralyzed 
side. She is almost completely aphasir, her repertoire of words being con- 
fined to u yes'" and u do," the forme!- being repeated several times hi 
answer to any questions she may be asked. When she is asked 1km- name, 
Bhe i- unable to tell it. " Is it Jane?" she shakes her head and smiles. 

•• I- it Ann?" another shake of the head, and an attempt to speak, the 

only result being the production of an unintelligible noise. " Is it Mary?" 

when Bhe brightens up and says, '* Yes, yes, yes ; Ma "prolonged, 

and she generally gives it np in disgust. She cannot write, but makes a 
disorderly scrawl ; although we team from her friends that in health Bhe 
wrote well. She gesticulates a great deal, and endeavors to attract the 
attention of those in the ward, and evidently appreciates everything that 
goes on about her. Her pupils are easily dilated, but she does not Bee 



1 bled. Time's and Gazette, Dec 21, 18G7. 



APHASIA. 171 

with the right eye, and on examination I find atrophy of the optic disk. 
During the winter and spring of 1875—76, she seemed to sutler much from 
her pulmonary trouble. There was oedema of the lower extremities, which 
increased so that the anasarca became general, but she was somewhat 
relieved by digitalis and iron; diarrhoea supervened, and she finally died 
on the second day of June, 1876. 

Autopsy The dura mater was considerably thickened, and presented 

the appearance of old pachymeningitis. There was no lesion to be dis- 
covered in either third frontal convolution, but an old (dot was found in 
the right caudate nucleus. This clot was about half an inch in diameter, 
and was surrounded by some dense tissue. Cortical lesions were present 
on both sides of the brain, but of superficial extent, and confined chiefly to 
the parietal convolutions; these consisted of softened patches in advanced 
stages of degeneration. The cerebral arteries contained patches of a yel- 
lowish or atheromatous nature. The spinal cord was not examined. Both 
lungs were found to be tubercular, and in the middle lobe of the right there 
was a large cavity. I was unable to find any tubercular deposit whatever 
in the brain or its meninges. The left frontal convolutions were examined, 
but no disease whatever was found. 

Hemingway reports the following interesting case of left -sided paralysis 
with aphasia. 1 

Jane R., aged 30, widow ; occupation seamstress ; education fair, can 
read and write. Entered hospital October 30, 1873. Family history 
good ; says she always was a healthy woman till present illness. Admits 
having had a sore on genitals five years ago. Cicatrices are at present 
visible on forehead, which are probably a result of tubercular syphilides; 
says they came there five years ago. Her left eye shows the result of an 
old ophthalmia, which, it was supposed, was of gonorrhoea! origin. For 
two years past has had slight palpitations on exertion. Always used her 
right hand in her occupation. Four months ago, one night when she was 
going to bed she became suddenly speechless; there was no paralysis 
whatever. Next morning, on attempting to arise, found her left arm, leg, 
and side of face paralyzed; also, with loss of sensation in those part-. 
Loss of speech was complete; and hearing, which before this was excel- 
lent, was now lost in left ear. Her tongue was only affected in sensation ; 
she was not able to appreciate sweet substances placed on the tongue ; 
sense of smell also lost. About one month after this attack, i. c. three 
months ago, improvement began in speech, face, and lower extremity, and 
has continued since then. Upper extremity began to improve one month 
ago. Sphincters have not been affected. Is a medium-sized woman, 
pretty well nourished; mental faculties good, with exception of loss of 
memory, constituting well-marked amnesic aphasia. Is unable to recol- 
lect many words, names of objects, as hat, hey, handkerchief, pencil, etc. : 
though she can readily repeat them on being told, she forgets them imme- 
diately afterwards. Is unable to read continuously, omitting words, and 
giving up from inability to tix attention. On attempting to write the 
letters of the alphabet, the result was A B C D S 6 H I; but when the 
letters were separately told her, she wrote them down easily. Partial 
paralysis remains on left side of face; cannot close eyelids tightly. Sen- 
sation is lost to a great extent in left side of face, and in left nostril. 1 

1 .Medical lb cord. .March 1, 1S70. 



1 ( 2 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

not wince on the application of aqua ammonia to left nostril, nor when 
the conjunctiva or same side is touched with an irritant. Hearing poor 
on left side. Taste is impaired anteriorly and posteriorly on left side of 
tongue. 

Dynamometer, < . , ' - outer circle. 

( right, 80, ) 

^Estkesiometer is valueless, on account of loss of sensation of reaction 
to pain. Does not wince on pinching arm, but does on palm of hand and 
tips of fingers. Perception delayed; takes about three seconds. Can 
raise arm to level of shoulder, a little stiffly. Can flex and extend fore- 
arm and fingers, but slowly. Heart sounds normal. Walks without 
elasticity. Sensation in leg as in arm. Keflex action lessened. Electro- 
muscular contractility good. 

The accumulation of reported cases, however, in which the lesion Avas 
on the left side, leaves no doubt in regard to this question. Jackson 
and Ramskill report 40 cases of right hemiplegia with aphasia, and 
but one of left hemiplegia. Ogle 1 reports 2"> cases all with the lesion in 
the left hemisphere, though there were morbid changes in some of these 
in other parts. In not one of these where the lesion was on the left side 
was there undisturbed speech. Magnan 8 reported thirty-one cases of 
aphasia, and in all but four was there right-sided hemiplegia. Trousseau, 
in 18G8, had collected all the cases he could find, the number being over 
one hundred, and in all but ten there was right-sided paralysis. Seguin 3 
has collected 46 cases from the records of the New York Hospital, and in 
all but three there was right hemiplegia. Hammond has collected 243 
cases of right hemiplegia, with aphasia, and but 17 of left. Thus it is 
settled, I think, that the left side of the brain is that which contains the 
.speech-centre. 

The question as to the relative frequency of right and left hemiplegia 
naturally arises, and from the inspection of a large number of cases it will 
be -ecu thai there is a. very slight preponderance of the former. 

Browne, 4 from Baillarger's tables, says that " in aphasia, right is to left 
hemiplegia as 15 is to 1." 

By the following table it will be seen that there is x^vy slight prepon- 
derance of right -sided paralysis, and the comparison between the infre- 
quency of aphasia with left hemiplegia, ami the slight difference between 
the relative frequency of Occurrence of* both forms, is inconsiderable. 

( lases "f hemiplegia. K. L. 

Ogle ::» 43 82 

Andral 186 7:; (;.'{ 

Baillarger l H> 58 



v> 



821 17 1 117 



1 St . Geo. I [osp. Reports, vol. n. 

1 Bull, de V Academic de IVte'decine, 

■ Quarter!} Journal ofrftychological Medicine, 1861, xx.x, (JGiJ. 

1 \Y. Riding Reports, vol, ii. p, 284. 



APHASIA. 173 

As to the exact site, Regain tabulates 545 cases, in all of which but 31 
the lesion was in the left anterior lobe. Why the l<fi Bide is the seat, 
especially when embolism or thrombosis is the cause, has already been 
explained by the fact that the left middle cerebral artery is that which 

is in the most direct line from the heart. The next link in the chain, 
which is the question of valvular disease, and its connection with Loss Df 
speech, has been pointed out by 11. Jackson, who has found that valvular 
disease was nearly always associated with hemiplegia, and connected with 
loss of speech. He has seen more than 50 of these cases. 

In my own experience 1 , and my records show 8 cases of right hemiple- 
gia with aphasia in which I made autopsies, there were other Lesions, 
but always some trouble in the course of the middle cerebral artery. I 
therefore agree fully with the majority of observers, thai Loss of speech 
depends, except in rare instances, upon lesions in the left hemisphere, but 
that it may also follow a lesion in the other hemisphere, Both Brow n- 
Sequard and Van der Kdlk have advanced theories — the first, that articulate 
speech is a reflex process; and the latter, that it is seated in the olivary 
bodies. This last view was held by Willis, Solly, and others. Laycock 
is of opinion that these organs are "subservient to the emotions through 
the muscles of the face and tongue by language, and emotional cries and 
sounds." And he says : " It is by no means improbable, however, that 
the emotional movements of the hands, as well as of the tongue and face, 
are likewise under their direction. They are, therefore, to be considered 
as regulative ganglia to the motor centres of the facial, hypoglossal, and 
limb nerves in the medulla oblongata belonging to the substrata of the 
sensory tract." 

Dr. Herbert Major, 1 in a very complete article upon the microscopical 
anatomy of the island of Reil, sums up his conclusions as follows : — 

" 1. The cortical layers of the insula agree in number, order, and general 
arrangement with those of the vertex, but the cells of the third layer are 
in the insula generally smaller than at the vertex. The vessels and neu- 
roglia present no peculiarity. 

" 2. The various gyri forming the insula present a similar structure. 

"3. No difference of structure can be detected in the right as compared 
with the left insula. 

"4. The method of union of the white matter with the cortex is in the 
insula similar to that observed in other lobes." 

The departure from the healthy state is seem in enlarged vessels, a 
shrunken appearance of the cells of the first layer and a diminution in their 
number, together with even a change in the cell-contents, the nuclei being 
broken down and agglomerated at the centre. The cells of the second and 

third layers have lost their processes, and the protoplasm contains granular 
debris, while the other cells of the lowermost la) ers suffer the same changes 
as well as transposition. 

1 West Riding Reports, fol, ri. 1. 



174 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Aphasia may be dependent upon any form of brain disease which pro- 
duces disorganization of, or pressure upon, the third frontal convolution or 
parts immediately adjacent. 1 Among the common diseases which lead to 
the structural changes are cerebral hemorrhage, thrombosis or embolism, 
tumor, or sclerosis, as well as certain forms of meningitis. Age appears 
to play but a small part in the production of this condition, except so far 
as it influences cerebral hemorrhage, embolism, or the other diseases just 
mentioned. 

Very few examples of aphasia in very young persons have been reported, 
for \ascular neuroses are quite unusual among children, and right hemi- 
plegia, with a lesion in this particular part of the brain, is of rare occur- 
rence. A case was reported by Eulenburg which was quite unique. 3 The 
patient was eight years old ; two years before lie had had scarlet fever, 
and six weeks after the development of the disease there were convulsions 
and coma, followed by right hemiplegia with aphasia. The paralysis 
almost subsided in two weeks. He speaks but two words, viz. : " Ach," 
which he always uses for "nein," and " Ja," with which he answers 
all other questions. The fact that dropsy and albuminuria had existed 
induced the author to infer the presence of softening of the central organ 
of speech. That disease of the island of lleil is not always the cause of 
aphasia is proved, 1 think, by the fact that aphasia has existed with dis- 
ease of other parts of the brain while the speech-centre was in a normal 
condition; and tumors have been found involving the corpora striata, and 
other parts of the motor tract, but not affecting the integrity of the third 
frontal convolution. 

Aphasia of a temporary character may depend upon functional conditions, 
such as cerebral congestion, indigestion, or as the result of fright or other 
emotional forms of excitement, or may be connected with epilepsy or hys- 
teria. Kisch 3 reports three cases of transitory aphasia due undoubtedly to 
cerebral congestion. One of these was a very stout woman who, having 
drank a very large quantity of carbonic acid water, fell to the floor after 
being dizzy, but did not lose consciousness. This seizure was followed by 
headache, and later by complete aphasia. She subsequently recovered. 
Two cases of aphasia of a similar character are reported by Berger. 4 

Habershon 6 presents an example of aphasia, which was caused by fright. 
A much more rare variety of the disease is that which is connected with 



1 Among fifteen cases reported by Sander* there were two in which the origi- 
nal lesion was found in the left parietal lobe, in some of the bundles of fibres 
radiating from the corpus striatum. 

■ Berlin Med. Gesellschaft, .Ink, 1869. 

:1 Berliner Klin. Wochenschrift, iscn, t:;:;. 

1 Wicn. Med. Woch., I860, n»2. 

5 London Lancet, L870, vol. ii. -102. 



* ArVliiv fUr IVu-hiatric, ii. 



APHASIA. 175 

epilepsy. Three such cases were published by Allbutt.' One of these 
patients fell, striking on his left temple ; some time afterwards epilep- 
tiform attacks appeared with paralysis of the right arm and leg. The 
second case was that of a woman aged fifty, who had had epileptic con- 
vulsions of a bilateral character for two years. After the attack she 
was somewhat aphasic, and "had a mental vision of the words," but 
was unable to speak them. This condition of affairs lasted for two 
hours. The third patient was a man, thirty years of age; there was no 
loss of consciousness, but attacks of hyperesthesia in the right ana and 
hand, followed by blindness, lasted for twenty minutes or longer, and was 
succeeded by speechlessness lasting two hours. 

Diagnosis. — In making the distinction between aphasia and other 
difficulties of speech, we are apt to be misled by defects in articulation, 
dependent upon incoordination or paralysis of the tongue, or by certain 
mental irregularities, or sometimes by congenital mutism. 2 We are to bear 
in mind the fact, that there may be transitory aphasia, but that organic 
disease of the speech-centre is generally of permanent duration ; and that 
there are but very few exceptions to this rule. The speech defects which 
are of a local character are symptomatized by the patient's inability to 



1 Med. Times and Gazette, 1869, vol. i. p. 491. 

2 Dr. Browne,* of the West Riding Asylum, recently examined 29 cases of 
morbid affections of language, or all in the existing population of the Crichton 
Institution at Dumfries; 14 of these were females, and 15 males. Of these, 
which he arranged in three classes, he found among the women : " 1 . Intermittent 
mutism 5, in one connected with the catamenia. 2. Constant mutism, 7 : of these 
one had been a public singer ; 1 when roused could with difficulty articulate, 
having facial paralysis; 1 could not walk in consequence of spinal deformity; 
1 was an idiot laboring under phthisis; 1 uttered cries when suffering pain. 
3. One was reduced to monosyllabic utterances. 4. One manifested inces- 
santly, day and night, irresistible loquacity. 

Among the males: "Intermittent mutism, 1. 2. Constant mutism, 5: in J 
the mutism is of twenty years' duration ; in 1 it is accompanied by tremor of the 
limbs; in a third, who attempted to cut his throat, there is unintelligible mutter- 
ing in soliloquy. 3. One was reduced to monosyllabic utterances. -4. Two 
manifested constant loquacity : in one, an idiot, there is congenital left hemiplegia ; 
in the other, who is healthy, the loquacity is so great and rapid that the words 
run into each other so that he seems to speak in long sentences. 5. Two pre- 
sent symptoms of general paralysis; the articulation is indistinct or unintelligible. 
»;. In one case there appeared to be the omission of the first syllable of every word, 
followed by alternate mutism and loquacity. 7. In one, an idiot, language is 
limited to a few words, and these are exclusively oaths, with congenital right 
hemiplegia, and club-foot. 8. Two idiots emit nothing but acute inarticulate cries ; 
one roars like a wild beast." There was no paralysis in these cases except of 
the face in two general paralytics, and of the lower extremities in two idiots, the 
paralysis in these latter eases being congenital. 



* Op. eit. p. 'J!)7 



176 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

speak at all, though he may fully convince us of his ability to form words 
and appreciate their meaning; and, moreover, he can always, should there 
not be paralysis of the hand or forearm, write any word that he may wish 
to speak. This is not the case in aphasia. In lighter forms of tongue 
paralysis there is no trouble about the selection of words, but simply a 
clumsiness in pronunciation, and in many of these forms evidences of 
local muscular weakness, in connection with the speaking apparatus, 
draw attention to the real nature of the trouble. A disease presenting 
these local defects is a so-called glossopharyngeal paralysis. The same 
condition of affairs is met with in general paralysis of the insane, but with 
this, as well as other troubles of the same kind, there are various other 
symptoms which accompany the speech defect, such as mental impairment, 
with peculiar delusions and muscular trembling. Hysteria sometimes gives 
rise to a very curious speech derangement, which, in its strictest sense, can 
hardly be called aphasia. The patient occasionally introduces obscene 
and profane words in place of others more conventional. A form of speech 
trouble described by Winslow 1 and Romberg 2 is expressed by mimicry of 
individuals, who speak to the patient or who talk within earshot. He 
closely imitates the tones of their voices and mannerisms, and repeats the 
words addressed to him, besides mimicking their gestures and attitudes. 
These phenomena are occasionally seen among the insane. Romberg has 
called this morbid state echohdia. I have at present a case under obser- 
vation who is an example of this kind, only his infirmity does not exist to 
so marked a degree as in the cases of the two observers above mentioned. 
My patient is an idiot, and possesses but very little mental power, lie 
can point to his mouth, places his hand upon his abdomen when hungry, 
and can call attention to his bodily needs by equally simple gestures, but 
beyond this he is more an automaton than a living being. When asked a 
question, for instance, "How are you?" he repeats the two last words, 
"Are you?" and "Why don't you answer?" he replies, "Don't you 
answer?" lie invariably repeats the last two or three words of any ques- 
tion that may be put to him, so that his answers are but echoes of the 
question-. 

In the early speech disturbances of left hemiplegia, or organic diseases 
of the brain, the patient's attempts to articulate will result in a clumsy and 
mispronounced word ; while in aphasia, his articulation, he it ever so lim- 
ited, 18 rarely imperfect, his "yes" or " no" being fairly pronounced, or, it' 
be has improved so far as to be able to pronounce but a part of a word, he 
will do thi- distinctly, while perhaps the other syllables will either be not 
pronounced at all, or in such a. way as to be utterly unintelligible. There 
an; generally with aphasia great impatience and embarrassment, mimicry. 
and gesticulation, which are evidences of mortification arising from 
the knowledge of his failing, and his gestures take the place* of words. 
In agraphia the handwriting or results of attempts at writing must be 



1 Obscure Diseases of thg Brain and Mind, Am. ed., p. 348. 

-' A .Manual of the Nervous Diseases of Man, 8yd. Trans., vol. ii. p. 481. 



APHASIA. 177 

compared with specimens, such as would be made by patients who are 
insane, ataxic, or paralyzed, and it is necessary for us to carefully note the 
omission of words, or combination of syllables which bear no relation to 
one another, as well as the character of the patient's composition. If he be 
insane, he will not admit any absurdities to which he may give expres- 
sion, but with the aphasic the case is different, for he always evinces 
his chagrin when he finds that he has written the wrong word, and 
endeavors to correct his mistakes. There are cases spoken of by Bacon 1 
and others, in which the only evidence of the patient's insanity i- his 
writing, but even here the defect is more in the expression of a disordered 
mental state than in an impairment of the communicating faculty. The 
handwriting of the general paralytic sometimes closely resemble- that of the 
aphasic patient, but in the first, with time there is progressive impair- 
ment, while in the other, if anything, there is improvement. 

The medico-legal questions which may arise in regard to the responsi- 
bility of aphasia are worthy of consideration. The aphasic of course may 
suffer an intellectual impairment, which lasts a short time after the attack. 
This is not necessarily accompanied by a loss of judgment. It is more h 
condition of mental sluggishness, and it will not do to say that the indi- 
vidual is incompetent. The aphasic makes intelligent efforts to communi- 
cate, even though he may not be able to do so. He gesticulates, and tries 
to explain himself, and the expression even of his eyes tells of everything 
but intellectual unsoundness. Additional evidence of softening in dementia 
throws an entirely different light upon the matter, but even then it must 
be remembered that aphasia is not necessarily associated with such states. 

A case of interest is reported by M. Lucas Championnieres : 2 " The ques- 
tion was raised in this particular instance apropos of a case in which the 
patient, in spite of an enfeebled intelligence, had become capable of writing 
witli the other hand. He could not, however, write if left to himself, and 
could only recopy what was written and set before him, and the expert 
physicians vainly tried to make him recopy a power of attorney or a will, 
while he willingly wrote any ordinary phrase or document which did not 
bind him to anything. This man, then, knew perfectly what he was 
doing, and the Societe de Medecine Legale concluded that he possessed 
still thorough intelligence and free will to be able to continue to enjoy his 
civil rights, the intellectual debility which lie had Buffered not appearing 
to be sufficient to justify what the French laws call an ' interdiction.' ' 
The society recommended that he should be taken care of by a •• council." 
so that Ik 1 should be guaranteed protection against danger that might arise 
in the condition of his affairs. 

We must bear in mind the existence of heart trouble should it exist, or 
vegetations and other indications of extraneous disease which might lead 
to the causation of thrombosis or embolism. 



1 On the Writing of the Insane, p. 12. 

2 Journal de .Med. et de C'hir. Prat., ahst. Br. Med. Journ., Sept. 1 ."». Is; 

12 



ITS 



DISEASES OF THE CEREBRUM AND CEREBELLUM, 



Prognosis. — The view we are to take of our patient's condition is to 
he governed entirely by the question whether there is or not a primary 
organic disease, its importance and the character of the aphasia. 1 In the 
light forms, such as result from fright and cerebral congestion, or those 
connected with hysteria, the prognosis is exceedingly good, and the same 
is the case when it is the result of protracted fever. Legroux (op. cit. p. 
60) speaks of an aphasia of quite temporary duration, which is occasionally 
of gouty origin, or connected with diabetes or albuminuria. The prognosis 
of the condition itself is quite good, but a serious indication of grave cere- 
bral trouble. Aphasia with paralysis is always significant of deep trouble. 
Such an aphasia, when it occurs with hemiplegia, may persist perhaps 
during the individual's lifetime, and after every vestige of the hemiplegia 
lias disappeared. If there be softening, or previous acute cerebral dis- 
ease, or if there be evidence of arterial degeneration, or valvular deposits, 
the case assumes a, hopeless aspect, and may be nearly always pronounced 
incurable. Aphasia as the result of traumatism is occasionally relieved by 
surgical interference. 

Treatment. — Our first indication is to improve, if possible, the or- 
ganic disease, and sometimes we are able to better the patient's condition 
to a great degree. Should there be hemiplegia., contractures, or other evi- 
dences suu-<restive of defeneration of the cerebral tissue, we will find our- 
selves powerless to help our patient materially. It is only when aphasia 
exists as an isolated symptom that very active measures are followed by 
some show of success. In such a case local blood-letting, purgation, and 
the use of ergot, and the bromides, may completely relieve the condition; 
and even when the disease is established, and the destruction of the speech 
centre has been limited, there is a possibility of improving the patient's 
partially lost faculty. Systematic education, and the training of the left 
hand, and the development of the right side of the brain, may result in an 
increase in the patient's facility of communicating. In rare cases, viz., 
those of traumatic origin, it may do \\;ell to use the trephine. Broca, un- 
der the heading, " La Topographic Cranio-Cerebrale," 2 described experi- 
ments made by him to determine the relation of the cranial bones with 
underlying parts; and Turner 8 has made additional observations, and 
given rules for determining this relation. Figure 20 is taken from Tur- 
ner's article, and I have slightly modified it so that the point where the 
trephine may be used is indicated. This instrument may be also em- 
ployed in aphasic patients at parts where the depressions of bone have 
resulted from head injury. 

Kin-. 20. — "Diagram showing the relations of the convolutions to the 
skull. R. The fissure of Rolando, which separates the frontal from the 



1 In one case reported by Bateman, (lie patient recovered almost entirely, and 
] |( - could pronounce every word distinctly, with the exception of those containing 
the Idler P. 

a Revue d' Anthropologic, tome*v. N«». 2, 1876. 

:) Journal of Anatomy and Physiology, vols, xii., siv., 1878, L874. 



CEREBRAL SCLEROSIS 



179 



parietal lobe. PO. The parieto-occipital fissure between the parietal and 
occipital lobes. S. The assure of Sylvius, which separates the temporo- 
Bphenoidal from the frontal and parietal lobes. SF, MF, W . The 
supero-, mid-, and infero-frontal subdivisions of the frontal area of the Bkull ; 

Fig. 20. 




the 

tion 



External indication of Island of Reil. (After Turner.) 

letters are placed on the superior middle and inferior frontal convolu- 
SAP. The supero-antero-parietal area of the skull. I A P. '1 he 
infero-antero-parietal area of the skull. IPP. The infero-postero-parietal 
area of the skull; the letters are placed on the mid-temporo-sphenoidal 
convolution. O. The occipital area of the skull; the letter is placed on 
the mid-occipital convolution. Sq. The squamoso-temporal region of the 
Bkull; the letters are placed on the mid-temporo-sphenoi.lal convolution. 
AS. The ali-sphenoid region of the skull; the Letters are placed o*i the 
tip of the s.iporo-tomporo-sphenoidal convolution/' The circle indicates 
the point at which the trephine is to be applied. 



CEREBRAL SCLEROSIS. 

Synonyms— Sclerencephalia ; atrophia cerebri. Tab.- cerebri. Atro- 

ph\ of the brain. 

Definition.— An induration of the nervous Bubstance consisting in 
increase of connective tissue, and atrophy and destruction of the uervous 



180 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



elements, constitutes the condition known generally as sclerosis. The 
French writers have applied the terms " Sclerose en plaques disseminee," 
'• rubar.e \" " peripheriques," and " diffus" to the disease ; adopting these 
names in regard to the character, site, and form of the lesion. Such ex- 
pressions, while making the nomenclature more exact, imply delicate dis- 
tinctions which are not always to be made, and do very well only when 
applied to appearances witnessed after death, but are not so valuable 
when making a diagnosis before death. I prefer to use the terms "dif- 
fused sclerosis" of the brain, " cerebro-spinal sclerosis," and "spinal 
sclerosis." Even this nomenclature is open to objection, for it is very rare 
for sclerosis of any kind to be confined to either the brain or cord, though 
such involvement of the organ not originally affected may be of late date. 
To confirm this statement I may allude to the ocular symptoms which 
characterize the early manifestations of posterior spinal sclerosis, or the loco- 
motory defects that are to be seen in some sclerosed conditions supposed to 
be peculiarly cerebral. I may furthermore add that in all forms of sclero- 
-i- there are generally points of induration found after death in both brain 
and cord. Nevertheless, it is important for us to make distinctions in the 
manner and origin, course and termination of the various forms of the dis- 
ease, and we must therefore be contented with an anatomical division. 

DIFFUSED CEREBRAL SCLEROSIS. 



The older writers were in the habit of giving the title " atrophy of the 
brain" to a condition of that organ which was undoubtedly that which we 
are now discussing. It is probably one of the most imperfectly understood 
nervous diseases, and in many instances the diagnosis cannot be made 
during life. 

Symptoms The cerebral condition, which is tardy induration of an 

unlimited region, and does not consist in scattered deposits, is a slowly 
developed morbid state, and is expressed by a train of rather obscure 
symptoms, the most striking of which are contractions and epileptiform 
convulsions, impairment of mental power, and various affections of speech. 
In BOme cases the conditions date from infancy, and the characteristic fea- 
ture is want of development of the extremities. In others, a condition of 
imbecility exists, in which the patient leads almost a vegetative life. One 
case (No. II.), which I shall relate, was of this kind. Her last years of 
life were spent in bed, and for a long time there were dementia, and uncon- 
scious discharges from the bladder and bowels. Some of these cases begin 
later in life, and the first indications may he either tremor or an epilepti- 
form convulsion, and subsequently various disturbances of motility, such, 
for instance, as Spastic contraction of the muscles of the arm and leg. 
Tin- fingers become twisted, deformed, and distorted so as to be useless. 

Tremor is not rare, and as the disease advances there may be various 

Other symptoms, such as paralysis and muscular atrophy, as well as glosSO- 

labial paralysis. Psychical disturbances are early symptoms, and a species 

bf dementia is rapidly produced. 



CEREBRAL SCLEROSIS. 181 

Case I Mary J., the patient, a girl 14 years old, was brought to me 

during the month of September, 1871. She had been very ill some six 
years before, and from what I learned from the mother, the attack of 
illness must have been scarlatina, or some other eruptive fever. Her con- 
valescence was slow, and attended by convulsions of an epileptoid charac- 
ter. She slept much of the time, and seemed dull and stupid. Her 
memory became impaired, so that her mother was obliged to take her from 
school, and when allowed to play she quarrelled with the children in the 
neighborhood, and became so warlike that it was found necessary to keep 
her at home. When she had suffered for over a year in this way, she 
began to lose her power of speech, and when she attempted to converse 
with those who spoke to her she talked in an unintelligible manner; the 
tongue "seemed to be paralyzed." In 18G8 her arms became very weak, 
and trembling grew violent when she made any manual effort. This loss 
of power, which was observed more in the right arm, became so great that 
she was unable to use it in any way whatever. After a year or so the 
arm became rigid and atrophic, and within twelve months the other arm 
followed. She is now in a condition oi' imbecility. She holds her head 
very far forward when she walks, her ('bin being raised. The right pupil 
is slightly larger than the left. There is ataxic loss of speech, the tongue 
being entirely out of control, but nevertheless she incessantly trie- to 
talk. Her senses are but slightly impaired, and it may be said she hears 
well, if we can place any reliance upon the rough tests I made, such as 
speaking to her behind her back. Her sensibility to pain is not appa- 
rently lost, for she gives expression to signs of suffering when she is pinched, 
but she complains of dysesthesia. 

Her right arm, forearm, and hand are semiflexed and rigid, and the 
atrophy of the palmar muscles suggests the "main en griffe." Her nails 
are long and thick, and the skin not only of this hand, but that covering 
the hand and arm of the other side, is blue and cold. The flexors carpi 
radialis, palmaris longus, pronator radii teres, and other muscles upon the 
anterior aspect of the forearm were atrophied and contracted, as well as 
the extensors communis and minimi digiti. This appearance was found 
on both sides, but more so on the right. When she makes any voluntary 
movement, the tremor occurs, and it is like that which marks other forms of 
this disease; that is to say, it is increased by persistence in the attempt. 
The arms are the only parts affected by the tremor. Her convulsions 
occur about twice a week. 

Case II M. S., aged 18 years, admitted to hospital June 21, 1873. 

When patient was fifteen months of age she had her first epileptic con- 
vulsions. These, according to her stepmother, have gradually increased in 
number. At ten years of age she became paralyzed. The paralysis affected 
her right side, and came on gradually, without loss of consciousness : and 
it has increased so that at present all the muscles of the extremities, and 
some of those of the face, are paralyzed. Sensibility is not affected. She 

lias imperfect control of tin 1 voluntary muscles, and does not use them 
readily; and when spoken to does not appear to appreciate what is desired 

immediately. 

Dynamometer: left side 15, right side 19. 

The a'sthesiometer was not used, as the patient was too much demented 
to appreciate what was wanted. 

Her head is very large, the patient being of ordinary Mature. The 
Bftliva Hows continually from the corner of her mouth, and her complexion 



182 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

is dusky and bad. The muscles are all more or less atrophied. Heart 
and lungs are normal ; no murmurs other than the venous hum of anaemia. 

The patient came under my care in June, 187G. She was then in a 
condition of profound dementia. She had been in bed for some months, 
and when I examined her I found her condition to be the following : — 

There were no constant ocular defects, no ocular paralysis, and the 
pupils responded well ; but there had been occasional attacks of unconscious- 
ness, attended by nystagmus, when her eyeballs would move from left to 
right. There was slight paralysis of the buccal muscles, and the mouth 
was almost constantly open ; while a profuse secretion of saliva drooled 
from the angle of the mouth and over her undergarments and bed-clothes. 
Her mouth contained partially masticated food, of which there was an 
accumulation between her teeth and cheeks on either side. Her teeth 
were very filthy, and the gums tender and bleeding. No appreciative 
facial paralysis was detected. When spoken to she smiled in an inane 
manner, but did not attempt to speak. She was occasionally very apt to 
cry for several hours at a time, and seemingly without cause. Her posi- 
tion in bed was an exceedingly uncomfortable one ; she usually reclined 
upon her left side, the head drawn down to the same side ; and it was 
agitated by coarse tremors, which ceased when she slept. Her right arm 
and forearm were drawn to her chest, and likewise agitated by almost 
constant tremors. Her left arm was also adducted, and the forearm semi- 
flexed ; while the fingers were extended. Tremors of the same character 
agitated this member. The thighs and legs were drawn up, but did not 
-<(iu to be quite so rigid as the arms, and there was great atrophy of all 
four extremities. She passed her excreta unconsciously, and a bedsore 
had formed upon the left buttock. Voluntary power was absent almost 
entirely, and I do not remember having seen her change her position in 
bed from the time I first saw her until her death. Sensibility to pain was 
very much lost, and reflex excitability was nil. Perhaps some of this 
want of sensibility was due to the horny condition of the plantar skin. 
She had a great many general convulsions, attended by turgescence of the 
surface vessels, and nystagmus. She continued in this condition during 
the year, improving slightly during this time in regard to the number and 
violence of convulsions, but gradually 'growing weaker. 

Dec 26, 1876, 1.30 P. M. Being fed with stewed meat she had 
three convulsions in rapid succession, while her mouth was filled with food. 
Attendant states that she first became cyanotic, but her teeth were so 
clenched that the nurse was unable to extract the food. As soon as the 
Spasms relaxed, she thrust 1km- fingers in the mouth of the patient, and re- 
moved a piece of meat, but the patient was dead. 

Autopsy IK hours after death. — No food found in larynx or fauces. 
Membrane of brain congested and thickened; the gray matter of all the 
convolutions was of the consistency of the white of a hard-boiled egg. 

1 afterwards carefully examined the brain, and found patches of advanced 

sclerosed tissue over the cortex, and throughout the gray and white matter 
of other parts of the hemispheres. The induration was so general that 
i he brain seemed, as a whole, quite hard and tough. The arteries were 

diseased throughout, and the calibre of the vessels was quite reduced. 
CASE III This patient presents evidences of Cerebral sclerosis, which 

were evidently of very early origin. The patient is at present in the Epi- 
leptic and Paralytic Hospitajl Her early history is somewhat meagre. 
She gives a history of epilepsy, and has attacks several times a week. Her 



CEREBRAL SCLEROSIS. ] 88" 

mind is very feeble, and she has attempted suicide several times. The 
atrophy is one-sided, and there is probably atrophy of the left Bide of the 
brain. The following history and table of measurements were furnished 
by my predecessor, Dr. Janeway : — 

E. B., aged 19 years; state, single. Admitted to hospital May 1, 1€ 

Examination Head: no facial paralysis or deviation of tongue; no 

atrophy of tongue; pupils normal, no strabismus ; hearing good, as is also 
common sensibility. Right upper extremity: shoulder-joint ts freely 
movable; elbow cannot be fully extended ; hand flexed and extremely 
pronated ; muscles of hand to a certain degree rigid ; fingers flexed, thumb 
not rigid ; marked atrophy of entire arm ; skin of fingers sofl and sodden, 
but no other changes of nutrition. 

Measurements Middle sternal notch to coracoid process : right Bide, 

4^- inches ; left side, 4| inches. Edge of acromion to external condyle: 
right side, 10J inches; left side, 10^ inches. External condyle to styloid 
process of ulna: right side, 7 J inches ; left side, sj inches. Apex of 
acromion to styloid process : right side, 7^ inches ; left side 8 inches. 

1st metacarpal bone (index finger): right side, 50 mm.; ht'i Bide, 55 
mm. Metacarpal bone (little finger) : right side, 47 nun.; left side. 50 
mm. Metacarpal (thumb) : right side, 40 mm.; left side, 43 mm.; light 
index, 65 mm.; left index, 70 mm. Little finger: right Bide, 53 mm.; 
left side, GO mm. 

Thenar eminence, thickness of: right, 31 mm.; left, 35mm. Hypo- 
thenar eminence, thickness of: right, 20 mm.; left, 2 1 mm. 

Vertebral prominence to edge of acromion : right side, (>£ inches ; left 
side, 7^ inches. Inner edge scapula to supra-spinal notch, to deltoid : 
right side, 12§ inches ; left side, 14§ inches. Length inner border sca- 
pula : right, 5£ inches ; left, 5J inches. 

Semi-circumference thorax (4th rib): right, 13 J inches; left, 14^ 
inches. 

Sensibility of right hand normal in every respect. Dynamometer: first 
trial in left hand, 18; second trial, 10. Hardly any power of right hand. 
but reflex movements are readily excited in it. Circumference : right 
arm, 8^ inches ; right forearm, 8^- inches ; left arm, 9£ inches ; left fore- 
arm, 9|| inches. 

Lower extremities: left, length of fibula, 13J inches; right, length of 
fibula, 13^ inches; right calf, 11^ inches; left calf. L2| inches. Lower- 
edge patella to lower edge external malleolus: right, 13^ inches; left. 1. 
inches. Anterior edge inner malleolus to end of great metatarsal : right, 
4| inches ; left, A\ inches. Circumference over heads of metatarsal hone- : 
on right side, 1\ inches; on left side, 7^ inches. Anterior sup. spinous 
process to lower malleolus: right, 28£ inches ; left, 28| inches. Supra- 
sternal notch to lower edge of external malleolus: right. l.\[ inches; left. 
48| inches. 

Sensibility of legs good in all respects. Difference of malleoli as she 
lies in bed, J ; inch. 

Causes So little is known in regard to the circumstances favoring 

the development of this disease, that beyond the mention of certain facta 
of age and sex nothing more can be said in connection with etiology. 
Women seem to be more affected than males, and we ma\ consider that it 
is usually a condition that begins in infancy and progresses Blowly, or 18 
arrested; or, on the other hand, it may begin in advanced lite, and pre- 



184 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

gress more rapidly. In one ease which I have seen, syphilis had 
probably something to do with its development. 

Morbid Anatomy — Those authors who have made autopsies have 
found a condition of density of the white matter, the same being* shrunken 
and more firm at the centre of the hemisphere than at the periphery. 
When a microscopical examination is made, the brain-tissues are found to 
.-how appearances which are highly characteristic. The connective tissue 
will be found to be proliferated, and to present a fibrillatcd appearance. 
Corpora amylacea are often present, and we usually find granular deposits 
in the blastema. The new tubes are quite changed in character, and are 
shrunken and attenuated. The axis cylinder may have disappeared, and 
its place may be tilled by a granular substance. The nerve-cells are greatly 
altered, their prolongations being torn off, and their contents granular. 
Oil-globules are often found scattered over the field, and sometimes col- 
lected about the bloodvessels. These vessels are generally much increased 
in size, and their walls are thickened, and covered by a granular deposit. 
If the gray matter be the part affected, we shall find an unusual develop- 
ment in the bloodvessels. 

1 have spoken of the involvement of the cranial nerves. It is not un- 
common to find at the roots of this nerve a sclerosed point which has 
involved the nuclei. 

Diagnosis Diffused sclerosis, in its incipiency, maybe mistaken for 

cerebral softening, but though the two diseases seem very much alike, the 
absence of severe pain, and variations of temperature in the latter, as well 
as subsequent progress of the disease, will enable us to decide; it must be 
borne in mind, however, that in the great number of cases diffused sclerosis 
begins in xvvx early life. The congenital non-development which we 
sometimes see will be recognized by the absence of tremors. 

Prognosis and Treatment The former is excessively bad, and 

even temporary relief, I think, is out of the question in the great majority 
of cases, i have never seen a case cured ; and if there is any disease of 
tin- nervous system that is utterly beyond the reach of drugs, I am con- 
vinced that it is this. The actual cautery has been used, but, as far as I 
can learn, without benefit. Hammond recommends chloride of barium, 
and claims to have improved tlie condition of the patient. 



BRAIN TUMORS. 185 



CHAPTEE VI. 

DISEASES OF THE CEREBRUM AND CEREBELLUM 
(Continued). 

BRAIN TUMORS. 

When the brain chances to be the scat of a morbid growth, whether 
vascular, parasitic, homologous, or heterologous, we may be apprised of 

the existence of such a new formation by a train of symptoms which have 
no very constant character; or the tumor may involve a large part of the 
brain without giving rise to any indications of its presence during the life 
of the patient. There is no regularity as to the grouping or appearance 
of symptoms, although the very valuable researches of Hughlings Jackson 
have enabled us to define the position of the morbid intracranial growths 
with much greater certainty than heretofore. 

Symptoms We may group the prominent symptoms under the 

following heads : — 

1. Convulsions. 

2. Vomiting and vertigo. 

3. Headache and cutaneous hyperesthesia or anesthesia. 

4. Hemiplegia. 

5. Paralysis of cranial nerves. 
G. Ocular symptoms. 

7. Psychical disturbances. 

Convulsions. — The appearance of convulsions as the only indication of 
brain tumors lias frequently led the observer to make a diagnosis of epi- 
lepsy. However, when it is taken into account that there is. at the most, 
but transitory loss of consciousness — and even this is very rare — during 
the epileptiform attack, such a mistake is hardly possible. The convul- 
sion- may be general or local, and in this place it is proper to refer 
to the connection between certain cortical lesions produced by brain tu- 
mors, and consequent convulsions beginning in members which are sup- 
posed to have motor centres. Among sixteen cases collected by Hughlings 
Jackson there were several in which the convulsive seizure began in the 
thumb of one hand, and finally became general. Cortical lesion- were 
found in the third frontal convolution. In another the epileptiform 
seizure began in the right cheek, and still another i:» reported where the 
right arm was the point of seizure, with subsequent paralysis; and after 
death a tumor was found in the Uppermost frontal convolution on the op- 
posite side. Upon the authority of Bastian 1 and Reynolds. " it may be 

1 Op. eit., p. 493. 



180 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

stated that convulsions are most common when the disease is situated in 
the posterior lobes of the brain or in the cerebellum, and least frequently 
when the anterior lobes are affected." 

Hughlings Jackson considers that psychical disturbances are likewise 
connected with destruction or injury of the posterior lobes. When the 
growth is syphilitic, the presence of much headache before the convulsion 
is the rule. Convulsions may be the first symptoms of tumor, and when 
they occur in advanced life there is always occasion for suspicion. Several 
writers have agreed that convulsions and other symptoms are the result of 
irritation of parts adjacent to the tumor, and that they may vary in ap- 
pearance and severity in proportion to the local disturbance created by 
the growth ; for this reason convulsions may appear in the most irregu- 
lar manner. Pain is one of the earliest and most persistent symptoms. 
It is nearly always localized, and is very intense, especially if the me- 
ninges be affected in any way, when it may be combined with muscular 
twitchings. It is rare for it to subside for an extended period, and then 
reappear; and in such cases it is highly probable that the growth lias 
either expanded in some other direction, or that the tissues have become 
accustomed to its presence in the manner suggested by Niemeyer. Pain 
aggravated at night is highly suggestive of a syphilitic tumor. 

Photophobia is sometimes a symptom, and intolerance of noise is a de- 
cided feature, while vertigo is produced by very slight irritation, and it has 
been found in tumors which injure the corpora quadrigemina that this 
occurs when the patient closes his eyes. Such was noticed to be the case 
in an example reported by Dr. Duffin. This patient, a man aged twenty- 
five, presented the following symptoms : A dragging of the muscles at the 
back of the neck, so that the head was pulled downwards and backwards, 
unsteady walk, vertigo when eyes were closed, vomiting, frequently slow 
and irregular circulation, obscured intelligence, double optic neuritis, de- 
fective sight, and finally coma. A gliomatous tumor was found which had 
destroyed the pineal gland, and extended into the optic thalamus. Heel- 
ing is commonly associated with vertigo, and is generally symptomatic 
of a growth in the substance of the cerebellum. Symptoms of minor 
importance are cutaneous anaesthesia or hyperesthesia, with tingling or 
formication of the hands or feet. Such anaesthesia may affect the tract 
supplied by the fifth nerve, while deep cerebral pain may coexist. This 
combination i> almost pathognomonic, and should be looked upon with 
suspicion. 

Hemiplegia is not an uncommon symptom, and may he sudden when 
produced by the rupture of a, vessel; or of gradual origin, as the result of 
pressure male upon important parts of the motor tract by a tumor of slow 
growth. It is generally a late symptom, and may begin by paralysis of one 
member, and afterwards of the other of the same side. By far the most 

interesting paralyses are those of the cranial nerves, because of their value 

88 diagnostic >igns ; and not only in; t \ the optic nerve be affected, but the 

auditory motor oculi, ami even the fifth, may Buffer an alteration of func- 
tion. 



BRAIN TUMORS. 187 

Jackson and others are of the opinion that those muscles concerned 
more in the execution of direct voluntary movements are often affected 
in a greater degree than those which perform automatic movements almost 

exclusively. 

Paralysis of both external recti muscles occurred in one of Jackson's 
cases, and is, perhaps, one of the most significant indications of tin- pre- 
sence of a gummata. Lateral deviation of the cyc< from the Bide of the 
lesion is also a form of cranial nerve paralysis which is by no means a 
rare symptom. In a case reported by Afanaschiff, 1 where a tumor was 
found in the right cms, there was dilatation of the pupil and ptosis. Par- 
tial paralysis of the face, showing involvement of the seventh, and actual 
deafness, arc not rare consequences of injury sustained by the seventh 
nerve. 2 When the fifth nerve is affected, as in one of Broadbent's cases, 
there is generally marked anaesthesia of the region supplied by this nerve, 
with difficult mastication, deglutition, and articulation. The most im- 
portant changes, however, are seen at the fundus oculi, and by some optic 
neuritis is considered to be a positive sign of brain tumor. Iviissel. 3 in 
the description of a very instructive example, details an examination of 
the fundus. This may be considered a typical case, although the retinal 
appearances were in an advanced stage. He found " loss of vision com- 
plete, neuro-retinitis of both eyes. Right disk comparatively invisible, 
even its position not clearly distinguishable. Position of left disk indi- 
cated by short portion of retinal vessels, which were visible near their 
point of convergence. Region around the disk in each eye occupied by 
large irregular patches of hemorrhage, some recent, others undergoing 
absorption. Only very small portions of retinal vessels are here and there 
visible." 

Complete atrophy of the optic disk is generally to be observed in cases 
where the retinitis has existed for some time. 

Hughlings Jackson calls especial attention to the fact that loss of vision 
is not inseparable from optic neuritis, though complete blindness often 
does occur. He has seen cases in which there was double optic neuritis, 
though the patients were able to read the smallest type.* 

A very important appearance observed at the fundus, and known as 
" choked disk" or " congestion papilla." is often produced by brain tumor-. 
In fact, when not a peripheral condition, it is almost always, according to 
Swanzy, 5 connected with intracranial tumors, hydrocephalus, or menin- 
gitis; but when it is produced by these morbid conditions it is Usually 
binocular. " Choked disk" may be caused by a tumor in any part of the 
brain, whether it be in the cerebellum or cerebrum, and it is not necessary 

1 Wien. Med. Woch., 1870, No. 9. 

2 II. Jackson does not believe that tumors of the cerebrum or cerebellum pro- 
duce deafness, unless the auditory nerves /» ]>>•<*.<<(/ upon. 

3 Med. Times and Gazette, July 26, is::;. 

1 Royal London Ophthalmic Hospital Reports, vol. i\\. 1865. 

1 Signs of Congestive Papilla or Choked bisk in Intracranial Disease. II. 1!. 
Swanzy, M.B., F.R.C.S., Dublin Journ. of Med. Science, June. is74. 



188 



DISEASES OF THE CEREBRUM AND CEREBELLUM, 



that the optic nerve shall be implicated either at its origin or in its course. 
Another fact is of importance, viz., that the size of the tumor has nothing 
to do with the production of the condition, and a small tumor may pro- 
duce choked disk as well as a large one. The appearance of choked disk 
is, in substance, the following. The disk may be seen to be prominent, 

Fin. 21. 




Choked Disk. (After Leibrcich.) 



the fibres are swollen, and the papillary region is sometimes of a dark red- 
dish-gray, much change of color being due to passive effusion and old 
hemorrhage. The disk may, in other cases, be of a bright color. There 
may be some evidences of retinal extravasation, which are not found at 
any great distance from the edge of the disk, and Albutt 1 says not more 
than a distance of the radius from the edge. The margin of the disk i> 
concealed by infiltration and by vascularity, which give it a "mossy" 
appearance. The central radiating appearance resembles very much a 
scintillating body, while the retinal veins are distended and tortuous, are 
quite serpentine in their course, and they may even be varicose. 

I cannot agree with Albutt. who considers the recognition of any prom- 
inence of the disk a difficult matter, and I think that this is the opinion 
of the majority of ophthalmologists. 

Speech is generally involved at some time or other, and psychical trou- 
bles of all kind>. but more frequently the asthenic forms, make their 
appearance. There is often a condition of hebetude and stupidity which 

i- BUppOSed to Bymptomatize a tumor in the posterior lobes, or there may 

be mental decay of a most grave character. Delusions, loss of memory, 
change of temper, Buicidal tendencies, and various perversions of intelli- 
gence ma) occur in any case.^ 



The Ophthalmoscope, etc., 1871, p. 55. 



BRAIN TUMORS. 189 

A feature of cerebellar tumor, which I find was also observed by Caton, 
was the assumption by the patient of the erect position as a means of relict* 
from the nausea and desire to vomit. This author, 1 in reporting a case of 
cerebellar tumor, alludes to the inability of his patient to regulate hie 
visual coordination ; and this seems perfectly reasonable when we consider 
the paralysis of the muscles of the eyeball, and the diplopia, amblyopia, 
and other disturbances of visual regulation. 

The case of Miss F. is in some ways instructive, although it lacks 
completeness, as it does not contain the report of an autopsy, the patient 
being still alive (Oct. 1G, 1877) :— 

Miss F., aged 37, U. S., school teacher ; was sent to me by Dr. 
Richard F. Derby, in July, 187G. Seven months ago her present trouble 
began with weakness of vision, for which she consulted Dr. Derby, of 
Boston, who adopted Dyerization as a means of treatment. In Novem- 
ber, 1876, she began to complain of severe localized headache on the left 
side of the head. This symptom was constant for three months, and to- 
wards the end of this period a gradual hyperesthesia of the entire left side 
developed itself, which is now present. It is more decided for three or 
four days at a time, when there is a lull. There is also strabismus, which 
attends the paroxysms of acute head pain, which once in a while recur. 
In December, 187G, there was some vomiting, which did not have any 
connection with the fulness or emptiness of the stomach. There is no loss 
of motor power in the upper extremity of either side, but the left leg and 
foot are rather weak, and there is some awkwardness in progression, the 
toe dragging slightly. Slight impairment of electro-muscular contractility 
of muscles of leg and thigh. Dynamometer on left side, 9 ; on right, 12. 
Slight ptosis of left eye, occasional diplopia, 

Dr. Derby's record of the examination of her eyes : " Neuro-retinitis 
o. u., with great reduction of vision o. s. ; moderate reduction o. d." The 
patient hears subjective rushing sounds on left side. Is slightly hysteri- 
cal, and suffers from menstrual irregularities. She gives no history of any 
traumatism, no blow or fall, nor previous illness. Her mother and father 
are living, but of decided nervous temperament ; paternal aunt and some 
of mother's connections are insane. Maternal grandmother and her 
brother died of phthisis. The patient has had night-sweats, and some 
pulmonary symptoms. There is no specific history. 

Upon a previous visit she stated that there was great formication in the 
sole of the right foot. She afterwards went to her home in Vermont, when 
I lost sight of her, but have subsequently heard of the advance of her 
symptoms. 

Morbid Anatomy Without attempting any classification, I will 

briefly allude to those forms of intra-cranial growth most often met 
with. Probably that which is most common is Tubercle, Among voting 
children tubercle is found sometimes in masses of considerable >i/e; and, 
according to AYilks, the cerebellum is its mosl familiar Beat. It i- found 
as a cheesy accumulation of dirty green color, and very rarely has the gray- 
ish appearance of the deposit been found in other parts of the body. Thes 



■se 



1 London Lancet, Oct. SI, L875. 



190 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

masses are rather dry. and decidedly non-vascular, and if a collection has 
been arrested in its growth will be found to be encysted, and may be 
readily removed. If of progressive growth, the limits of the deposit are 
blended with the surrounding brain-substance, and of a consistency like 
cold, white glue. Tuberculous masses are rarely single, but generally 
invade several regions in the same brain, so that it is impossible to give 
any very satisfactory table which will throw light upon the question of 
distribution. 1 

Fox, in speaking of Jaccoud's observation, says: "I much prefer Jac- 
coud's account of these tubercles. They occupy the white and the gray 
substance equally, and present themselves under the form of small isolated 
circumscribed masses, varying in number from one to twenty, and seldom 
exceeding the latter. Their volume is in inverse ratio to their number. 
Pretty often they are the size of a cherry, at other times they scarcely 
exc ■! the size of a grain of wheat. As to the colossal masses which 
attain to the magnitude of a hen's egg, they result from the confluence and 
fusion of several spots originally distinct." 2 

They are sometimes separated from the nervous substance by a sheath 
of connective tissue and bloodvessels. In this connective tissue, which 
is well filled with vessels, according to Virchow, 3 the new granules are 
formed, and are impacted with the central mass, and become cheesy. 
When the process stops, the growth is found to be surrounded by a tough 
fibrous coat, which is sometimes very hard, and even calcified in old cases. 

Ogle 4 has reported a case where the tuberculous mass had broken down, 
so that it was soft and pultaceous. In the younger subjects tubercle is 
generally found in other parts of the body. 

Cancerous growths in the brain, which seem to affect those of ad- 
vanced age, take much the same form that they do in other parts of the 
body. Encephaloid and scirrhus are the commoner forms, though melano- 
mata are occasionally found. 

The investing membranes may all be the seat of cancer, but notably 
the pia mater and the bony walls of the cranium are its starting-points. 

1 Grasset* has classified brain tumors: 1. Those of the embryonic tissue, (tissu 
embryonnaire). These are the Sarcomata — a. Soft sarcoma; />. Sarcoma nevro- 
glique (glioma) ; c. Sarcoma angiolithique (or psammoma). lie considers that 
the terms glioma and psammoma arc improperly used ; that the first term suggests 
more the consistence rather than the character of the tumor. 2. Those of the 
connect ive tissue, which are — a. Myxoma,; />. Fibroma; c. Lipoma; </. Carci- 
noma; i. Melanoma. :S. Those of the cartilaginous tissue, Chondroma. 4. 
Those of the OSSeOUS tissur, Osteoma. ">. Those of the ,/>if/i> lid/ tissue, Papil- 
loma. 6. Those of the nervous tissu, , NYuroma. 7. Tubercle. 8. Syphilitic 
Tumors. !>. Parasitic tumors (Hydatids), Aneurism. 10. Abscesses. 

2 Fox, op. fit., p. 1 .jl . 

> Cellular Pathology, p. 523. 

1 Articles in Br. and For. Med.-dhir. Review, L864 and 1865. 

3 

Maladiec 'in Systftme Nferveux, Parte ami Montpellier, 1378, p. 802. 



BRAIN TUMORS. 



191 



In this case the cancerous mass grows inwards, where it meets Less 
resistance, while cancer of the brain itself grows outwards. Cancerous 
masses are occasionally very large, and in one of Russel's cases (to which 
allusion has already been made) the cancerous mass, which occupied the 
right parietal region, weighed six ounces and a half. These tumors pre- 
sent the same characteristics which they possess in other region-. The 
encephaloid variety is very vascular; the scirrhus not so much so, and is 
quite hard. The carcinomatous growth presents the usual appearance of 



Fig. 22. 



Fie. 2:5. 




Tubercular Deposit about Vessel. 



Sarcoma. 



cells contained in the alveoli of a fibrous network or stroma. It may ex- 
ist alone as an intracranial growth, or coexist with cancer of other organs. 

Fig. 24. Fisr. 25. 




Guimtiii 



The cancerous growth invades the cerebral Bubstance, though generally 
the dura mater and the other meninges m.i\ lie the parts at first affected. 



192 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



Syphilis very often produces changes in the contents of the cranium 
which are quite formidable. Of diffused infiltration I will not speak, but of 
those growths known as gummata, or "gummy tumors." The meninges 
and cortex cerebri are commonly the parts which favor the syphilitic 



Fiji. 26. 



Fie. 27. 




Encephaloid. 



Glioma. 



deposits, though deeper regions may very often be invaded by the trans- 
lucent reddish-gray tumors of specific origin. The interior is sometimes 
j<]ly-likc and soft, and contains minute red points, while the periphery 
is hard and fibrous. The tumor proper appears to be separated from the 
surrounding brain substance by this fibrous covering, though there is 
always infiltration into the parts adjacent. Syphilitic growths are rarely 
single, and 1 have seen a number of them in the same brain. Beneath 
the microscope the tumor seems composed of round cells about the size 
of white corpuscles, containing a single nucleus. These round cells 
occupy the centre of the mass, while'the outer portion is composed of a 
network of connective tissue containing irregular cells.' The dura mater 
is very commonly the point of origin. This case, for the history of which 
I am indebted to Dr. Ryan, was diagnosed by him during life. The 
patienl was in the service of Dr. Mason. 

William Browning, set. .'V2, native of the United States, boatman by 
occupation, married, was admitted to the Paralytic and Epileptic Hospital 

Of BlackwelFfi Island, on .March 13, 1*77. 

The patient -av> he has always been a hard drinker. Had been a very 

healthy man up to seven years ago, when he contracted syphilis, and has 
since thai period been subject, from time to time, to outbreaks of the dis- 



1 The syphilitic growth may sometimes he mistaken lor thai of a tuberculous 

nature. Nieine\cr h.i> reminded us, however, " that in syphiloma the passage 

from the cheesy centre to the broad, gra) ish-white peripheral /.one is \ cry gradual, 

while in infiltrated growing tuberculi these zones follow each other more closely, 
and in tuberculea thai can be turned oul the} do nol exist/' 



BRAIN TUMORS. 103 

ease in its tertiary form. Two years ago he had a convulsive attack, 
which occurred at night; after which he was out of his mind tor three 

weeks. Since that time he has been subject to one or two attack- occur- 
ring every month. Since admission, the patient had four epileptiform fit-. 
characterized by clonic spasms, a confused and perturbed condition of the 
mental faculties, but no distinct loss of consciousness. A premonitory 
feeling of great terror was always experienced about ten or fifteen minutes 
prior to the convulsion, and this sense of dread remained for some time 
after each fit; these seizures being always followed by intense headache 
and debility, which generally lasted for several days. The patient's sight 
had failed greatly for the last year; unfortunately no ophthalmoscopic 
examination was made. His memory, he said, was getting \^r\ much 
impaired, and any mental occupation caused violent headache. 

April 28, the date of his last attack, he had been in bed, complaining 
of severe pains in the head, referred chiefly to the frontal region of tin- 
right side. This pain was always greater at night ; the patient complained 
of no other trouble, with the exception of great weakness and anorexia, 
until about May 5, when slight paralysis of the muscles on the right >i<l<- 
of the face was noticed, especially of the orbicularis palpebrarum. There 
was also a distinct loss of muscular power in the left upper extremity, 
which was colder to the touch than the right, and the pulse of the affected 
limb was feeble and compressible. On May 14 the patient became some- 
what-delirious, and remained so till the time of his death. On the 17th he 
began to cough, and expectorated a great quantity of sero-mucous fluid. 
Mucous and subcrepitant rales were heard over all the anterior surface of 
both lungs; a change in the pulse and temperature, which had previously 
remained normal, was now noticed; the former being 130, and the tem- 
perature 103°. Herpes appeared on the forehead and lips. On the 
morning of the 18th, patient was in a semi-comatose condition. Pulse 
1G0, temperature 104°. He died at 2 o'clock P. M. of same day. 

Autopsy twenty -four hours after death. Rigor mortis passing off"; body 
somewhat emaciated ; suggillation of posterior portion of body. Old 
cicatrices (large) over left tibia, also several smaller ones scattered over 
exterior and upper portions of body. 

Head : The dura mater is markedly thickened over portion of the parie 
tal bone of right side adjacent to temporal bone, and is also adherent to 
a tumor beneath in the brain-substance. On three points on inner sur- 
face of parietal bone (right) are spots of necrosis, the size of a dime, 
which involve the inner table. The dura can easily be separated from 
the bone, but not from the surface of the tumor. This tumor is three 
inches from above downwards, and two and one-half inches from before 
backwards. It is firm, and of a yellowish color. The brain-substance 
directly beneath it is the seat of softening (intlam.), while beyond this 
point, and extending in a direct line to optic thalamus of right side, the 
brain-substance is softened and diffused. The outer border of posterior 
portion of optic thalamus is in the same condition, while the meninges and 
vessels are normal. 

Thorax: Lungs. Bands of adhesion on right side, and a few at apex of 
left. In the lower lobe of right are numerous spots of lobular pneumonia in 
gray stage. On anterior margin of right lung some einplivsema, and also 
at apex of left lung. Otherwise both lungs >how marked hypostatic con- 
gestion and oedema. 

Heart soft and flabby. Seat of post-mortem decomposition. 
13 



194 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Abdomen : Liver increased in length ; evidences of peri-hepatitis. On 
surface of liver are seen several old cicatrices, which dip down into liver 
substance. The parenchyma in patches is softened and fatty (syphilitic 
liver ?). 

Spleen increased in size. Capsules thickened in patches ; parenchyma 
diffluent. 

Kidneys about normal size. On stripping capsule it brings away por- 
tion of kidney tissue. Surface appears granular, and in some points shows 
lobulation. Section shows tubules swollen, and of yellowish color. There 
appear to be about normal relations between cortical and pyramidal por- 
tion-. Pelvis and ureters normal. 

Bladder, stomach, and intestines normal. 

Parasitic Growths (Hydatids and Cysticerci) Hydatids are always 

contained in a delicate cyst (except when they occupy the lateral ven- 
tricles), and there may be several in the same capsule. The cysts are of 
variable size, and sometimes attain the magnitude of a fair-sized orange 
(Reynolds). They are occasionally very large, and the centre of either 
hemisphere seems to be their common site. Cysticerci, which are very 
small, and are sometimes contained in cysts, rarely exceed the size of a 
large marble, but are, however, more often found uninvested, and they 
may be from one to several hundred in number. They prefer the cor- 
tex, and are often found beneath the pia mater. It seems to me that 
these would be among the most interesting cases for the observation of 
irritation of the motor centres; usually, however, there are very slight in- 
dications of their presence. 

Romberg, while making some experiments, found that the existence of 
cysticerci in the cerebelli of several sheep accounted for the peculiar roll- 
ing convulsions that he had observed. 

Cysts, which are not the secondary result of softening or hemorrhagic 
disease, are very rare, and are not usually larger than pin-heads. 

Glioniata, which are directly formed from the connective tissue, are 
more common in the posterior lobes*and in the cerebellum than in any 
other locality. The soft and firm are the two varieties. 

G. L. C.j at. 26, of nervous temperament; general health good; 
parents both alive ; no nervous tendency; never had syphilis. Four years 
ago the patienl became irritable and morose, and continued SO till January, 
1*7.5. He then devoted himself 1<> hard study, and rarely took exercise 
or amusement. Two months afterwards he became debilitated, and had 

attacks of vomiting, which occurred in the morning, and were relieved 
Bomewhal by the upright position. In the following April a loss of steadi- 
ness of the lower Limbs was noticed. He reeled, and a sudden fright would 
cause him to fall. He no longer went alone on the street ; when he did 
-«.. \\c reeled, staggered, and felt conscious that he was the object ot 
curiosity. His face became congested, ami his nose very red, although 

his habits were very good. He went to the seashore, but nevertheless 
grew worse, and derived no benefit from the change. About this time 
diplopia troubled him, mid he ttfed \ arious devices to correct this visionary 
difficulty, such as Bhuttingvrme eye and looking across his nose with the 
other, but without relief. In August, violent headache developed itself, 
and vomiting was frequent. He could not look up or throw his head back 



BRAIN TUMORS. 195 

without dizziness and pain. Cathartics and local blisters did no permanent 
good, nor did the bromides. 

May, 1875. The patient presents the same symptoms. He is very 
mucli troubled by headache, which is paroxysmal. He staggers wildly. 
and his vision is not improved. On the day before his death he went to 
see some friends, and on his return complained of a terebrating pain in the 
back of his head. lie went to bed, and slept, under the influence of 
chloral hydrate. When his wife awoke in the morning, she found him 
dead. He had evidently died without any convulsions, or she would have 
been aroused. The night before his death there was some mania, and he 
shouted words of the different languages he spoke — German, French, 
Italian — in a confusing jargon. 

At no time was there impairment of speech or deglutition ; there were 
never ptosis, deafness, loss of smell or taste. Paralysis was never observed, 
nor were there convulsions of any kind. 

Autopsy eight (?) hours after death. The scalp was cut through, and 
the exposed surfaces were almost black with blood. On removing the 
bone the meninges were found hyperaemic to a marked degree, the spaces 
were engorged beneath the arachnoid, and in the ventricles was a large 
amount of yellowish fluid, the former being puffed out by the serum 
under the surface Nothing unusual was noticed in the hemispheres 
beyond the hyperemia before alluded to, and careful slicing of the basal 
ganglia revealed nothing of importance. The texture of the nervous sub- 
stance was normal. At the base of the brain a very different state of 
affairs was found to exist. From before backwards there were evidences 
of acute inflammatory action, the left side more particularly being the seat 
of softening. The right crus of the optic commissure was very much dis- 
organized. There was a well-organized membrane, very pink and net-like, 
which extended over the inferior surface, one band binding down the left 
root of the optic commissure. 

Beneath the lining membrane of the fourth ventricle, at a point beneath 
the lower and anterior part of the cerebellum, was an effusion, with soft- 
ening of this organ. This membrane was bellied out, and had evidently 
produced death by direct pressure upon the calamus scriptorius. 

At a point corresponding to the middle of the lower vermiform process 
of the cerebellum was a small hard tumor, about two centimetres in length, 
one and a half in breadth, and the same in thickness, which, when cut, 
disclosed a red jelly-like centre, and a hard fibrous exterior, resembling, 
somewhat, a syphilitic growth. The line of demarcation between the 
healthy tissue and the circumference of the tumor was very well marked. 
Beneath the microscope Dr. E. G. Janeway and I found it to be a glioma 
of the firmer kind, there being a fibrous structure containing the charac- 
teristic cells. 

After hardening pieces of the cerebellum and the medulla oblongata. 1 
examined them microscopically. The evidences of disorganization of the 

nervous elements at the nuclei of the vagus were apparent. The nerve- 
cells were deprived of their processes, and the nerve-tubes were broken. 

The sections of the cerebellum were made contiguous to the tumor, and 

here I found considerable thickening of the neuroglia and disappearance 
ot nerve-tissue, while the vessels were veiw much increased in >i/e. 

Amyloid bodies, connective tissue cells and \e<-el< are found to compose 
these tumors, which may sometimes attain a diameter of several inches. 
The peri-vascular spaces are idled with adventitious matter, and the calibre 



196 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

of the vessels is very much reduced. These growths may undergo fatty 
degeneration or absorption. The hard varieties, I think, predominate, 
and they are very easy to recognize. 

Papillomata, both of the vessel and meninges, are not uncommon. 

My xo mat a, which Jaccoud describes as having their source of origin 
from the spheno-occipital suture, are quite rare, as are Lipomata. The 
former are usually of large size, have a gelatinous appearance, and at 
times are cloudy. The latter consist of large cells filled with fat, and are 
transparent and shining. 

Sarcomata may be met with as soft masses, which contain "fusiform 
bodies, nuclei, and vessels," or else round cells closely packed. They are 
tabulated, and, when cut, present a pinkish-gray and softened surface, and 
sometimes contain central fluid. The soft sarcoma, according to Grasset, 
is found among young children in the deeper parts of the brain, and remains 
dormant for some time, not giving rise to any symptoms, the cells being 
usually round ( u globo-cellulaire"). With fatty degeneration the tumor 
may undergo a change, so that it resembles the yellow plates in cerebral 
softening. It usually has a surrounding vascular network, and is easily 
separated from the brain-substance. 

Fibrous tumors are quite rare, but are sometimes met with. Lebert has 
Been, in one case, seventeen small fibrous tumors upon the ependyma of 
the lateral ventricle, varying from the size of a pea to that of a small 
cherry-stone. These tumors are of a white color and globular shape, and 
they are separated from the healthy brain-tissue by a space in which the 
vessels are enlarged. They are easily enucleated, and quite hard and 
dense. 1 

Aneurisms One of the most interesting and important forms of intra- 
cranial growths arc those of a vascular character. I have taken occasion to 
refer to the smaller aneurisms described by Bouchard and Charcot, the so- 
called miliary aneurisms, which are of minute size ; but large aneurisms, 
arising from such arteries as the middle, anterior and posterior cerebral, 
basilar, and communicating arteries, may be even an inch in diameter. 
These, with miliary aneurisms of small size, are generally found to coexist 
in the brain. Gougenheim 3 has found that aneurism of the basilar artery 
was much more common than any other form, and that of sixty-eight cases 
seventeen were of this artery. It is rare, however, that the disease can be 
diagnosed during life, and hut two or three cases have been reported where 

their presence was recognized by symptoms, and afterwards verified by an 
autopsy. One of these cases was reported by Coo, 3 another by Holmes, 4 
;uii| ;i third by 1 lumble. 5 

An interesting case of cerebellar aneurism is reported by BristOWe : — 

J. li.. a lighterman, aet. 56, was admitted on the 26th of October, 1858, 



1 An.it. Path., vol. ii. p. 7J. 

1 Gougenheim, Dub. Jpurn. of Med. Sci., Nov. 1870. 

' Association Med. Journal, Nov. 1855. ' System of Surgery. 

• Lancet, Oct. 2, L875. 



BRAIN TUMORS. 197 

for an attack of acute rheumatism (gout?). No distinct account of tin- 
previous duration of his illness was obtained. Five days after admission 
he complained of severe epigastric pain, and had some vomiting. Shortly 
afterwards he became comatose, and continued so until hie death, which 
took place on the 2d of November. 

Post-mortem Examination There was a considerable amount of serum 

both on the surface and in the ventricles of the brain ; and much athero- 
matous and earthy deposit in the arteries at the base, and their branches. 
In the right corpus striatum was a small apoplectic cyst, but in other 
respects the brain-substance appeared healthy. In the substance of the 
right hemisphere of the cerebellum was accidentally discovered an aneu- 
rism about twice as large as a grain of wheat ; it was irregularly fusiform ; 

Fij?. 28. 




Cerebellar Aneurism. (Bristowe. 



its parietes were thickened and hardened with atheromatous and earthy 
deposit, and it gave off several partly ossified branches, each about half a 
line in diameter. Its anterior extremity was continuous with a thin 
walled healthy vessel, having between one-third and one-half the calibre 
of the aneurism itself, and found to be a branch of the right superior r< ru- 
bellar artery. Gouty indications were found at different points. 

Occasional intracranial growths are the psammomata which are found 
as sandy little bodies scattered over the dura mater, and have a calcare- 
ous formation, feel gritty when rubbed beneath the fingers, and may he 
crumbled. Examined microscopically with a low power they may he 
found to consist of small, compact, round bodies, imbedded usually in the 
dura mater. 

Cholesteatoma, or pearly tumors, which are composed chiefly of choles- 
terine, stearine, and degenerated epithelium contained in an investing 
membrane, are occasionally present in the brain. The hit tor growths are 



1 Trans, of Path. See. of London, vol. \. p. I. 



198 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

generally found attached to the meninges or cranial bones, and are nearly 
always superficial. 

The literature of intracranial bony growths contains much that is inte- 
resting. One case reported by Yulpian in the Archives de Physiologie 
was remarkable for the slow development of an exostosis from the temporal 
bone, which completely penetrated the Gasserian ganglia on the right side. 
Beyond neuralgia of a severe character, no other symptoms were ex- 
pressed. I have seen many of these bony growths, some of them even 
several inches in length, which had existed for years without any mischief 
being produced. In slow growths there seems to be an accommodation 
of the brain so that the pressure is rarely injurious, and it is generally not 
till the exostosis attains some size, and atrophy or softening takes place, 
that had symptoms make their appearance. 

A case which was under the care of Dr. Janeway at the Epileptic 
Hospital is one of the most remarkable of which I have ever heard, and I 
append his very valuable record of the post-mortem examination. 

A. T., aged 42 years ; widow ; domestic. Admitted to Hospital De- 
cember 31, 1872. Patient says that fourteen months ago, as she was 
crossing the Jersey City ferry, she fell down, and heard the people say 
that some one had had a fit. When she came to, she found that she 
herself had had a convulsion. During the attack she was perfectly con- 
scious of all that passed about her, and, on arising and attempting to tie 
her bonnet strings, she found that she could not do so on account of what 
she Bays was numbness of the hands or arms. 

April 29, 1874. For the past five days she has been very dizzy, and 
has had headache, and pain in the left side under the breast. 

30th. Is in bed. Says " her back feels as if it was breaking in two." 

May 1. Is quite weak. Can move her left leg somewhat, but not her 
left arm ; her emotions are easily excited ; pulse weak ; temperature, 
1011°. 

2d. Pulse good ; temperature, 101°. 

3c?. She lies with eyes half parted, and does not open them fully when 
spoken to. Pupils normal and respond to light. Answers questions in a 
slow, whining tone, and with seeming difficulty. Does not draw up her 
legs when told, but they respond to reflex irritation. The severe pain in 
her back still continues, and she has some pain under left breast. Pain 
on pressure in the right iliac region. Bowels free;; urine normal ; respi- 
ration normal ; temperature, 1<>0°. Is somewhat stupid ; has great pain 

in back of her head ; eyes half closed; conjunctiva not very sensitise; 
passes urine and feces in bed. 

1///. Sleeping; foees of brown color ; urine passed in bed ; respiration, 

28; pulse, 88. P.M. Feces and urine passed in bed; tongue dry and 

coated brown. Only partially protruded tongue when told to. Eyes half 

closed; seems brighter ; respiration, 86 ; pulse, 100; temperature, 102°. 

.~>r//. Complains of pain in abdomen; bowels did not move last night; 

Cries when spoken to; pain in hack lighter, but in head is sharp. Pulse, 

88; temperature, l<»<> at ll o'clock A. M. P.M. Patient better; urine 
highly colored ; no albumen.* 

10th, Still pain at base^Sf skull. Temperature, 101 J . 

[2th, Temperature, 100}°. 12 M, Temperature, 99 ; headache not 
i ere. 



BRAIN TUMORS. 199 

June 2. No headache ; cries when spoken to. 

C)t//. Headache not severe ; pain in her back ; has passed urine and 
feces in bed for four weeks past. 

9tk. Temperature, 10(H°. 

1G7/*. Lies with head turned to left. Complains of pain when position 
of head is changed. Headache is relieved by bromide of ammonium. 

19M. Complains of no pain. There appears complete muscular relaxa- 
tion. Cannot speak without crying. 

'l^tli. Patient is rapidly failing. Temperature, 103j°; pulse, too rapid 
to count; respiration very quick ; conjunctiva insensible; pupils respond 
slowly to light. 

2\st. This morning about the same ; can swallow wine. P. M. Patient 
sank gradually, and died at 4.30 P. M. 

Post-mortem 18 hours after death Heart, liver, lungs, spleen, and 

kidneys normal. An abscess found in right Fallopian tube containing 
about £ij of pus. Kigor mortis not well marked. 

Skull On removing skullcap, an outgrowth of bone is noticeable on 

the right side, near the central line, just posterior to the groove for the 
middle meningeal artery. The growth is nearly two inches long, and 
one inch wide ; raised about ^ of an inch from internal surface. The dura 
mater was pretty firmly attached at this place, and little pieces were left 
attached to the exostosis. There is another bony projection (small) just 
back of the middle meningeal artery, at the inferior angle of the parietal 
bone. Otherwise interior of skull appears normal. The lowest first (1st) 
is situated just anterior to the fissure of Sylvius, | inch below posteriorly, 
and | inch from above downwards. Elevation, jfths of an inch. This 
has produced a corresponding depression and flattening of the commence- 
ment of the lower end of the transverse convolution of the anterior lobe. 
Two smaller ones are situated one just ^ of an inch above it, the other ~ 
inch above, and about ^ anteriorly. They are nearly half an inch apart, 
the posterior being the longer, and about T 9 oth of an inch in diameter. 
Elevation, T 7 ^ inch. 

Around the first large tumor three small ones exist ; the second small 
one is about one-third the size of the first. A bridge of new formation 
connects this with the two already described. At the point of the large 
exostosis, a number of tumors spring forth from under surface of the dura 
mater, close to one another, averaging 1 j inch in diameter. One of these 
tumors is quite large, and is sunk in a depression in the brain ; the depth 
is ^ of an inch, and it is an inch long and broad. The brain-tissue around 
this is in a state of pulpy softening. The diameter of the softened part of 
brain is two inches, and nearly reaches the longitudinal fissure, extending 
two inches downwards to within two inches of anterior border of' the brain. 
The fa Ix throughout its extent is the site of new formations, some project- 
ing on the right, others on the left ; one very large one in front, which is 
1J inch in length, and has an elevation of |fths of an inch : and another 
which dips into a depression in the anterior lobe of left Bide. 

The pia mater covering both hemispheres is markedly cong 
Tumors are linn, white, and yield only a thin serous fluid on scraping. 

Diagnosis. — It is a difficult matter, when we consider the great 

variety and irregularity in the appearance of symptoms, to make always a 

correct diagnosis. This branch of neurology is undoubtedly the most 

puzzling, and I am inclined to differ from those persons who consider it 



200 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

possible to determine in the majority of cases the exact location of a cere- 
bral growth. The fact that brain-tumors are very often multiple, and that 
secondary lesions are produced, is enough to cool the ardor of the most 
enthusiastic diagnostician. It is possible, however, to sometimes make a 
very close diagnosis. Localized pain and convulsions, with optic neuritis, 
cranial palsies, and vomiting, suggest very strongly the probability of tumor 
In speaking of the character of the paralysis, its gradual appearance, and 
its limited field, I have said enough to demonstrate that, generally, there 
is no reason why we should confuse this symptom with the paralysis of 
softening, although softening may sometimes be secondarily produced by 
the growth, and then there is much more difficulty in deciding on the 
nature of the trouble. 

It behooves us to make, if possible, a diagnosis of the nature of the 
tumor, and sometimes a very slight circumstance will suggest the real cha- 
racter of the growth. 

The localization of cerebral tumors has received very extended conside- 
ration during the past few years. In the many cases collected by Jack- 
son we are enabled to make a much closer diagnosis than before his excel- 
lent investigations were presented. Ogle's large number of cases are more 
of interest in the light of morbid anatomy, and as they are several hun- 
dred in number almost every variety of formation is to be found. Quite 
recently an excellent article by Petrina, of Prague, 1 has appeared. His 
directions for localization are so complete that I think it wise to present 
them, especially as they are based upon a number of cases. 

I. Tumors of the Convexity Clonic spasms limited to single groups 

of muscles on the side of the body opposite to that of the tumor; no loss 
of consciousness ; incomplete hemiplegia, constant headache, decided ver- 
tigo, nervous irritability; amblyopia and disturbances of hearing ; circum- 
scribed affection of sensibility. The localization of circumscribed motorial 
disorders is not definite, and can be only limited at present to the region 
of the anterior and posterior central convolutions. 

II. r rn mora of the Anterior Lobes Frontal headache; the intellectual 

sphere being involved (?,A. McL. II.) there will be often psychical disturb- 
ances, with chorea; paresis or hemiplegia (the former more frequently) ; 
no disorders of sensibility ; general convulsions with loss of consciousness 
ig rare, except when there is deej) pressure ; visual disturbance and deaf- 
ness, with anosmia. 

III. Tumors of Parietal Lobes* — Hemiplegia on opposite side preceded 
frequently by apoplectic attacks; aphasia very frequent when tumor is 
large enough to compress the third frontal convolution ; general convul- 
sions with large tumors; disorder of special sense, except vision, quite 
rare; impairment of cutaneous sensibility common ; frontal headache. 

I V. '/'a mors i>i' tin- Occipital Ldlics But one of Petrina's cases pre- 
sented opposite Bided paralysis*$ritb paralysis of the third nerve on the 
' - 

1 Yirrtcljulirsschrifl, flier die pr.-ikt. Ileilkundc, cx.wiii. 1. 2. 



BRAIN TUMORS. 201 

same side; disorders of intelligence; convulsions, involvement of organs 
of special sense, cutaneous derangements of sensibility are mentioned 
by Rosenthal and others as pathognomonic : but are not observed by 
Petri n a. 

V. Tumors of the Motor Ganglia Hemiplegia on opposite side, with 

loss of consciousness and frequent convulsions ; profound cutaneous anaes- 
thesia when the internal capsule is destroyed ; sometimes aphasia ; corpus 
striatum; complete hemiplegia with loss of consciousness and convulsions ; 
psychic disorders and irritative motor phenomena, such as tremor and cho- 
roid movements; disorders of organs of special sense are rare, with the 
exception of amblyopia. 

VI. Tumors of Optic Thalamus Extensive motorial symptoms are 

not constant, and general convulsions or disorders of sensibility are rare. 
"According as the tumor affects more the bundles of fibres going to the 
optic tracts or those branching out from the cerebral peduncle, we have 
sometimes predominating paralytic phenomena in the optic nerve, altera- 
tions of the pupil and disturbances of the innervation of the ocular mus- 
cles (nystagmus, exophthalmos) ; sometimes, again, there are the most 
remarkable vaso-motor anomalies of circulation (striking alteration- of 
temperature, and cyanosis, or circumscribed redness), as the chief morbid 
symptoms. Pronounced disorders of speech (retarded speech) and of the 
intelligence are symptomatic only of quite extensive tumors in the thala- 
mus ; decided paralytic phenomena are likewise characteristic of simulta 
neous destruction of the peduncular fibres, or of one of the motor gan- 
glia." 

VII. Tumors in or about the Pituitary Body Somnolence, mental 

weakness, or apathy ; slowness of speech. Amblyopia and amaurosis are 
common, as well as disorders of other organs of special sense. Rosenthal 
demonstrated that diabetes is an important complication of tumor in this 
region. 

VIII. Tumors of the Peduncles of the Cerebrum Vaso-motor disor- 
ders and anomalies of temperature ; early paralysis of the third nerve on 
the same side, as tremor, occasional vesical paralysis ; opposite hemiplegia 
with sensory disorders; intelligence unimpaired; optic nerve often in- 
volved ; involuntary movements of limbs on side opposite to tumor. 

IX. Tumors of the Cms Cerebelli Intense headache and vertigo, in- 
voluntary lateral decubitus, rotation of body, one-sided deviation of axis 
of vision, reeling gait, and tendency to fall; commonly disturbances of 
organs of special sense. ( Vide Caton's Case, A. McL. II.) 

X. Tumors of Cerebellum. — Headache quite intense, and limited to 
sub-occipital region, vertigo, reeling gait, disorders of coordination ; 
paresis of opposite side of body ; convergent strabismus, diminished elec- 
tro-muscular contractility on sound side of head. 

XI. Tumors of Pons. — Cross hemiplegia; ocular paralysis (convergent 
strabismus), lingual paralysis ; cutaneous anaesthesia, double or single, dys- 
phagia ; disorders of special senses; facial nerve involved; crossed sen- 



202 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

sory troubles; vaso-motor disturbances; vertigo; increased electro-mus- 
cular contractility of parts supplied by the seventh nerve to galvanic cur- 
rent, but not to faradic current. 

Greisinger has written quite fully upon the diagnosis of the character 
of the growth. He considered that convulsion with psychical disturbance, 
but no paralysis, pointed to the presence of cysticerci, because these para- 
site- infest the uppermost layers of the cortex cerebri. 

In one of Jackson's 1 cases (No. 13) the signs of an old iritis enabled 
him to make a diagnosis of a gumma. Other marks of syphilitic disor- 
der may be taken into account. Nodes, old scars, eruptions of a tertiary 
character, and alopecia, as well as numerous unmistakable symptoms, such 
as rheumatism, night-sweats, etc., are confirming points in diagnosis. 
Aneurism, which is rare in early life, may be suggested by vertigo and 
subjective noises heard by the patient. In the case reported by Humble 
a diagnosis was made by the stethoscope. Cancerous tumors are very dif- 
ficult to diagnose, the age of the patient being our only guide, and we are 
left absolutely in the dark in regard to gliomatous and other non-diathetic 
tumors, although some of the German writers suggest that a history of in- 
jury generally precedes the first named. Tubercle may be suspected after 
a careful inquiry in regard to the patient's antecedents, and the recog- 
nition of the physical signs of deposit in the lungs. Parasitic tumors are 
generally attended by mental decay, and Hammond- 3 states that epilepti- 
form attacks are the first symptoms of such trouble. 

Prognosis Cancerous tumors prove fatal in from two or three months 

to a year, while syphilitic tumors are occasionally retarded in growth, and 
the patient may ultimately recover under energetic treatment, though 
when left alone they rapidly increase in size. I do not agree with Ham- 
mond in regard to the chance of spontaneous cure in aneurismal tumors, 
and feel disposed to consider any cases of sudden recovery as anomalous. 
The progress of non-diathetic growths is very slow, and the patient may 
live for many years, and finally die of some other disease. Gliomatous 
tumors are perhaps less formidable than are others, but after all more 
depends niton the Bite of the growth than its size and character. Death is 
preceded in most instances by coma. 

Holmes Says in this connection I " We know nothing at present of the 
diagnosis of intracranial aneurism, so that no treatment can as yet be di- 
rected specially to it. And, looking at the very free intercommunication 
of the four large trunks which nourish the brain, it seems unlikely that 
Burgical measures directed to any one of them would procure the consoli- 
dation of an aneurism situated on one of iis main branches." 

Treatment. — It has been my practice in every case to place the 
patient upon an anti-syphilitic course of treatment. The iodide, in in- 
creasing doses, until a very large quantity is taken during the day, will 

1 Medical Tjnfta and "Gazette, August i, 1874. 

2 l)isc;iM'< of the Nervous S\<inn, p. 801. 



BRAIN TUMORS. 203 

sometimes effect a cure. I have given mercury also, but cannot Bpeak bo 
favorably of its virtues. If the pain is excessive, I use the ice-bag, as 
recommended by Jackson, and find that it gives great relief. Hypodermic 
injections are very useful, and hyoscyamus (F. 71) and belladonna (F. 70) 
also do good. Galvanism I believe to be useless. Ligature of the carotid 
has been employed by Coe for aneurismal tumors, and although it was 
successful in the case he reports, I am inclined to think it is not only a 
dangerous but an uncertain measure. 



204 DISEASES OF THE SPINAL MENINGES. 



CHAPTER VII. 

DISEASES OF THE SPINAL MENINGES. 
SPINAL MENINGITIS. 

ACUTE PACHYMENINGITIS. 

The investing membranes of the spine ma}' be the seat of chronic or 
acute inflammation, together or singly, though there is generally a certain 
amount of coexisting myelitis, and consequently the meningitis is not an 
uncomplicated condition. In exceptional cases, however, the dura mater 
may be affected, and the resulting affection is known as Spinal Pachy- 
meningitis ; or the pia mater and arachnoid in other cases are the seat of 
such inflammation ; or the three membranes may be together involved. 

INFLAMMATION OF THE SPINAL DURA MATER, OR SPINAL 
PACHYMENINGITIS. 

Michaud 1 has given the name external pachymeningitis to the form 
which results from pressure made by diseased vertebras and coexisting 
witli Pott's disease, while other varieties have been described as internal 
hemorrhagic pachymeningitis (Meyer 2 ) and cervical hypertrophic pachy- 
meningitis (Charcot 3 ). The form described by Meyer is almost identical 
witli that which involves the cerebral dura mater, and in which there are 
thickening and encysted clots. As the name indicates, the form described 
by Charcot is confined chiefly to the cervical portion of the spinal dura 
mater. 

ACUTE AND CHRONIC SPINAL M F.XINGITIS. 

Symptoms. — This disorder, which commonly involves all three mem- 
branes, i> generally ushered in by a. chill, followed by elevation of tem- 
perature; a hard, full pulse; and excruciating pain. This pain is increased 
by any movement the patient may make. lie tries to relieve his Buffering 
by changing bis position and by keeping quiet, so that muscular rigidity, 
which is semi-voluntary, is often mistaken tor a. tetanic spasm. Tain 
darting along the spinal nerves adds all the more to his misery, and his 
Legs are forcibly drawn up. Hyperesthesia of the surface i> generally 
present, and reflex excitability is nearly always exaggerated in the earlier 
Btages. The bead is Bometimea drawn backwards by contraction of the 



1 Sur l.i M6mngite, etc. These, Paris, L871. 

2 Dcs Pachymeningitide, etc. Bonnse, 1861. 

3 Lemons but lea Fonctiona du Sys. Nerveux, \'<^. L, part 2, p. 243, etc. 



SPINAL xMENINGITIS. 205 

post-cervical muscles, and the appearance is presented which is bo well 
marked in cerebro-spinal meningitis. Should the meningitis be general, 
or extend upwards, the intercostal and phrenic nerves are finally involved, 
and asphyxia and death result. The tendency in many cases is towards 
chronicity, and very often there are secondary affections of the cord from 
pressure. The bladder and rectum frequently sutler to such a degree thai 
involuntary discharges of urine and feces result, but the former BOmetimes 
escapes the involvement. Should the disease become chronic, it exists in 
a modified form, the pain being less severe, and the contraction- of the 
limbs more marked. The skin is cold and hypera>t hotic, and reflex exci- 
tability is present to an extraordinary degree, the slightest pride of a pin 
being sufficient to cause violent retraction of the limbs. The muscular 
power is greatly reduced, so that the individual may be unable t<> take any 
exercise. The bladder trouble is much more marked than in the acute 
variety, and the patient may find it necessary to empty his bladder every 
few minutes. Obstinate constipation, distension of the bowels by wind, 
and gastric disturbances, are accompaniments. If the cord is involved, 
there may be presented symptoms of meningo-myelitis, and then paralysis 
of motion and sensation becomes marked, and the muscles undergo atrophic 
changes. 

The case of Mr. J. E. is instructive. He is a great sportsman, and 
up to four or five years ago was often exposed dining his hunting excur- 
sions. Four years ago, during one of these, he lay for several hours 
in a "battery," shooting ducks. The weather was cold, and he was 
directly exposed to a drizzling rain. On the same night he was seized 
with a chill, which lasted for nearly an hour, and, supposing he had 
"caught cold," he drank altogether nearly a tumblerful of whiskey. Dur- 
ing the night he became feverish, complained of pain in the back, vomited, 
and was delirious throughout the next day and the two following. Bis 
pain was excruciating, and the slightest jar of the bed caused him intense 
agony. At the end of fourteen days he was moved upon a mattress to the 
nearest boat, and from thence to the railroad, and was carried to his 
home by easy stages. For a month or so after, he was confined to his 
bed, the pain gradually becoming less intense, ami his strength returned 
by degrees. He presented himself to me with the history I have just 
detailed. For the past year he has had spinal pain, which he refers ti- 
the last dorsal and upper lumbar vertebra'. It is constant and worse at 
night, and increased by pressure. There is gastrodynia, and pains down 
the back of the thighs, which seem to increase after exercise. lie com- 
plains of loss of power in the legs, and cannot walk more than a block or 
two without being greatly fatigued, and at night his legs are jerked up 
during sleep. For the past year he has had great distress and discomfort, 
as he cannot hold his water, and is obliged to empty the bladder every 
few minutes. His bowels are SO constipated that he tinds it inrr-an to 
use an injection every night. Examination revealed pain upon pressure 
over the two lower dorsal vertebrae, analge.-ia and anaesthesia of tlie cuta- 
neous surface of the posterior region of thigh. The glutei muscles, a- well 
as the adductors of the thigh, were much reduced in >i/e. and did not 
contract as powerfully as did those in the neighborhood when subjected to 

electrical stimulus. His abdomen was tympanitic and greatly distended. 



206 



DISEASES OF THE SPINAL MENINGES. 



He had become despondent during the past year, and neglected his busi- 
In addition to the pain, loss of power, and the other symptoms I 
have enumerated, there has been a sense of abdominal constriction at the 
level of the painful point. Damp weather aggravates the pain, and he has 
periods of improvement, when lie goes to Florida or some other warm 
region. 

SPINAL PACHYMENINGITIS. 

Symptoms The forms of pachymeningitis cannot be during life 

separated as a rule. There may be no acute stage whatever, but a 
gradual appearance of symptoms indicative of slowly developed pressure 
upon the cord. The form described by Charcot, 1 runs its course in five or 
six years, and the cervical enlargement of the cord is the part which suf- 
fers the most. Pressure is made upon the cord itself, and upon the nerve- 
trunks, so that partial or total loss of function ensues. There is a painful 
stage, the premiere periode of Charcot, which lasts several months, the 
pain being intense at the back of the neck and in the upper extremities. 
With these pains there is rigidity of the upper extremities, and the head is 
drawn backwards and downwards in the manner I have before described. 
There are in addition formication and disagreeable sensations in the upper 
extremities, and some paresis, which ultimately increases, so that the in- 
dividual retains but little power. Charcot has observed eruptions of bulla3 
and pemphigus as evidences of lowered vitality. After this period there 

Fijr. 29. 




Deformity of Hand in Cervical Pachymeningitis (Charcot). 

is atrophy <•(' the paralyzed muscles, particularly those innervated by the 

ulnar and median nerves, while those which are supplied by the radial 

escape the atrophic change^ and deformity often results which somewhat 
resembles the main en griffe of progressive muscular atrophy. The pre- 



1 Op. cit 



SPINAL PACHYMENINGITIS. 207 

ceding cut from Charcot represents the appearance of the hand in this 
condition. 

Contractions of the paralyzed muscles ultimately follow the paresis, and 
the skin becomes decidedly anaesthetic, so much bo that a pin may be in- 
serted without any expression of suffering from the patient. Jt is \<iv 
rare for the lower extremities to be implicated, and the medulla seems to 
escape the effects of the disease, consequently troubles of deglutition or 
respiration are rare. The hemorrhagic or internal form of pachymenin- 
gitis runs a most irregular course, but the complicating spinal affections 
are apt to be much more marked than in the last-mentioned variety. The 
indications of internal pachymeningitis are throbbing pain in the back, 
sudden paralysis, and the other symptoms to which I have alluded. The 
disease is connected with hemorrhages, and consequently there are at inter- 
vals accessions of fresh symptoms. 

The large number of cases which were known as " syphilitic para- 
plegia" some years ago include many examples of chronic syphilitic 
pachymeningitis, which were then recognized as the result only of myelitis. 
The progress of the disease is much more slow than in other forms, and 
the patient lasts a very long time, and is sometimes quite cured by appro- 
priate antisyphilitic remedies. The acute zymotic fevers are not rarely 
followed by pachymeningitis, the following case being an interesting 
example of this occasional sequel of typhoid fever : — 

Two years ago Capt. S. recovered from an attack of typhoid, and with 
convalescence he gradually lost power in the right hand, right leg, left 
leg, and left hand, in the order I have named them (this is his statement). 
Preceding these conditions there were shooting pains running down the 
spine and around the body. He was paraplegic two months afterwards. 
During this time reflex movements were easily provoked. " When my 
feet came in contact with the foot of the bed, if the cold wood touched 
them they would fly up." He evidently had the contractions which are 
so clearly symptomatic of meningitis, and there was some constipation, but 
no bladder trouble except atony. His neck "felt stiff," and he was occa- 
sionally dizzy. The loss of power in legs has gradually returned. 

Present condition The patient walks fairly, with no apparent impedi- 
ments. The skin is slightly hyperacsthetic ; no atrophy of any muscle- ; 
has good muscular strength; there is slight tenderness produced by pres- 
sure over the vertebrae between the scapulas; muscular tension at hack of 
neck, and some pain with movement; slight distension of abdomen by 
flatus (he says this is a constant symptom) ; bladder and bowels in excel- 
lent condition; some very trivial effort required to urinate : no headache. 
but dizziness caused by looking upwards; no loss of power in hands or 
arms; no constricting band; patient can stand with eves closed. Co- 
ordination of delicate muscular acts unimpaired ; there are no twitchings 
at night left. 1 suggested the propriety of giving iodide of potassium in 
addition to ergot, which he had taken before. I also recommended the 
actual cautery. 

Causes According to (Jrisolle, 1 spinal meningitis is much more 

common among men than women, and three-quarters of the patient- are 



1 Op. cit., vol. i. p. 486. 



208 DISEASES OF THE SPINAL MENINGES. 

men ; and Calmiel considers it to be of much more frequent origin before 
the thirtieth year than afterwards. Cold and intemperance favor its ap- 
pearance, but, in the great majority of cases, it is of spontaneous origin, 
and has occurred in epidemics, at least so say the earlier French writers. 1 
In 1837 an epidemic appeared at London, Versailles, Avignon, Metz, and 
Strasburg, and there were no atmospheric causes nor any influences dis- 
covered which could account for its appearance. It is probable, however, 
thai the form of meningitis was cerebro-spinal, with the history of which 
we are now familiar. Alcoholic over-indulgence, syphilis, and injury, 
or vertebral disease, will account for the affection in some cases. Like 
locomotor ataxia it very often occurs among seafaring men who have 
fallen overboard, or have been obliged to stay aloft in damp, cold weather. 
Pott's disease has generally been supposed to have little to do with the 
etiology of the disease, but my own experience and that of professional 
friends who have had much to do with this class of cases, convince me 
to the contrary. In a case of this kind where I was enabled to make an 
autopsy, I found great thickening of the spinal dura, with fibrinous de- 
posits beneath that membrane and the bone, as well as some involvement 
of the nervous substance proper, which consisted in atrophy. Frac- 
tures of the spine, sometimes unrecognized, are attended by so much 
injury of these membranes as to give rise to symptoms which may be 
either supposed to be due to myelitis or simple concussion, but which are 
undoubtedly occasioned by an unrecognized fracture. Such a case has 
been reported by Mr. Hutchinson, in which the individual jumped from a 
height, alighting on his feet. 

Morbid Anatomy and Pathology The simple forms of spinal 

meningitis, that is to say the acute forms, present all the appearance of 
violent inflammatory action which we witness in cerebral meningitis: 
injection of the pia mater, serous or purulent effusions, together with 
in lilt ration of adjacent cellular tissues, more posteriorly than anteriorly, 
and perhaps some evidence of myelitis, but ordinarily the cord is healthy 
if t he disease be uncomplicated. The region affected is more apt to be 
at the upper part of the cord, but there may be inflammation of the me- 
uingea covering the dorsal or lumbar portions as well. It maybe circum- 
scribed, as the result of pressure from displaced vertebrae, or fracture, and 
this Limitation is more characteristic of pachymeningitis. The different 
membranes may be adherent to each other, and connected with the cellu- 
lar tissue in the vertebral canal. New growths beneath the dura mater 
are not common, but may be found sometimes between this membrane 

and the bones. In cervical pachymeningitis there is great thickening, 
and in old cases the nervous matter is eonipressed to such a degree that it 
is atrophied, and may be found to be hardly two-thirds its normal size. A 

lamellar arrangement of the dura mater exists, which is like that seen within 
the cranium, and the other membranes may be quite (indistinguishable from 



1 Sec articlefl in M6moirea de L' Academic Nationale de Med., t. \., Revue 

.Mr licale, Mini (.:./. Mr lir.ilr. 1842. 



SPINAL PACHYMENINGITIS. 200 

the dura mater, and consequently the conl will be found encircled by an 
almost homogeneous, tough, and thickened envelope. In the hemorrhagic 
form, there may be discovered encysted blood-clots which resemble those 
found in the cranial hemorrhagic pachymeningitis. The nerve-trunks 
within the vertebral canal will be found to be covered by the Bame dense 
tissue, and the peripheral portions of the nerves are often atrophied. 
Syphilitic inflammatory changes, alluded to by Buzzard, 1 are sometimes 
present, with gummatous growths in the nerves proceeding from the cord. 
The following case illustrates the morbid anatomy of meningo-myelitis 
of a quite extensive character: — 

Idiot; Chronic Spinal Meningitis; Myelitis; Lobular Pneumonia; 
Circumscribed Acute Interstitial Nephritis ; Chronic Cystitis. — 1). A., at. 
26, admitted June 22, 1<S77. No previous history of the patient could be 
obtained, except that she had been an inmate of the almshouse for three 
years previous to admission, where she was confined to bed entirely. On 
admission patient was very much emaciated; legs and thighs flexed. She 
was unable to talk, but almost continually screeched, especially at night. 
Two days before her deatli she had a slight diarrhoea. On morning of 
June 28 had elevated temperature, rapid pulse, and cough. Chest could 
not be satisfactorily examined, as she would not keep quiet. Moist rales 
were heard over entire chest. Patient became worse during the day, and 
died at 4 o'clock A. M., June 20, 1877. 

Autopsy twelve hours after death, made by Dr. Maxwell, the Curator. — 
Rigor mortis present ; body small, and very much emaciated; thighs 
flexed and adducted, and the legs upon the thighs, and contractured. Feet 
(edematous. Bed-sore over sacrum and nates. Fingers and thumbs are 
flexed; the cranium small; round, low forehead; hair dark; complexion 
brunette: eyes brown. 

Head — Bones: calvarium circular; antero-posterior diameter six inches; 
deep Pacchionian depression on right side. Dura mater and sinuses nor- 
mal. A little over three ounces of fluid in subarachnoid space. Pia 
mater over the convexity meshes is markedly elevated by (edema, and is 
opaque in latter situation ; it is also abnormally adherent over convexity, 
and in Sylvian fissure. Weight of brain and cerebellum 22 ozs. Exter- 
nally shows nothing except that the sulci are wide. Lateral ventricles 
are moderately dilated. Kpendynue appear normal. Cerebellum weighed 
H oz. Brain-substance of cerebrum and cerebellum, gross appearances 
normal. 

Spinal Cord. — Adhesion in cervical region, between dura mater and 
wall of spinal canal, so firm as to require section for its removal: also 
another point in dorsal region. Adhesions between Opposed surfaces of 
arachnoid in cervical region quite firm and general on the posterior sur- 
face; on anterior surface scattered filaments. On posterior surface of 
dorsal region a few filamentous adhesions. Dura mater in cervical region 
is appreciably thickened, especially the upper two inches. Pia mater cor- 
responding with these adhesions has brownish appearance, and is thick- 
ened. Veins of cord are filled. Nearly all dorsal portion of the cord is 
soft to the feel. Throughout cervical region the posterior and right lateral 
Columns arc to the feel firm and normal; have bluish-gray color, with 



1 Syphilitic Nervous Affections, p. 70. 
U 



210 DISEASES OF THE SPINAL MENINGES. 

yellowish streaks. The dorsal portion of the whole cord markedly soft- 
ened. Lumbar region and cauda equina, to gross appearances, show 
nothing marked. Dura mater surrounding vertebral foramina is thick- 
ened and adherent to sheaths of upper four or five inches of cervical 
nerve-. Posterior long fissure of cord of the dorsal region obliterated by 
firm adhesions of pia mater. 

Tim rax — Lungs softened; on right side adherent. Pericardium nor- 
mal. 

Heart weighs 4 oz. ; walls, in color and firmness, normal. Cavities 
contained partially decolorized clots. The mitral valve is the seat of 
chronic endocarditis. Chronic endocarditis at commencement of aorta. 

Right lung — patches of fibrinous exudation on pulmonary pleura (re- 
cent ) ; lower lobe posteriorly. Lobular pneumonias scattered throughout, 
showing red and gray hepatization. On opposite lung only few lobular 
pneumonias in upper lobe; in lower lobe, plentiful. Both lungs markedly 
(Edematous; small amount of mucus in bronchi. 

Peritoneal Cavity. — Stomach displaced; pylorus drawn downward to 
left, dilated. Peritoneum normal. Liver weighs 27 oz. ; parenchyma 
pale, otherwise normal. There are bands of adhesion between sides of 
gall-bladder; hepatic flexure of colon and duodenum. 

Spleen weighs \\ oz. ; apparently normal. 

Kidneys : each weighs 1-^ oz. Left kidney was deformed. Capsules 
of both strip normal. Surface of left shows several large depressed cica- 
trices. One prominent spot, yellowish, of circumscribed interstitial 
nephritis. Cicatrices, probably due to old circumscribed interstitial ne- 
phritis, seen from surface. Right kidney of normal shape; surface pale 
and smooth. Four nodules of acute interstitial nephritis becoming puru- 
lent are seen from surface. Pelvis shows mild catarrhal inflammation. 
Bladder is the seat of intense cystitis. 

Uterus and appendages found in a state of retroversion ; size corresponds 
witli that of other organs. 

Ovaries are large in proportion to size of uterus. Cysts in cortical 
portion, but no corpora lutea or cicatrices found. 

Stomach and intestines normal. 

Prognosis. — The patient's chances are sometimes good, even in the 
chronic form. Charcot 1 has cured one case of cervical pachymeningitis, 
and doubtless others have been equally successful. In the great number 
of cases, however, a fatal termination is the rule. In the acute form death 
may occur in six days, but Tourdes and Chauffard have observed cases in 
which this termination did not take place till the fortieth or fiftieth day. 
In acute purulent meningitis the pus may make its way out, pointing ex- 
ternally. Or forming an abscess in the muscular ti8SUe of the back. Cham- 
pion has seen a case of this kind in which the purulent contents of the 
vertebral Canal found passage through at the third lumbar vertebra, and 
formed an abscess in the spinal muscles. This, however, is exceptional. 
When the dixase results from Pott's disease, or some other vertebral 
affection, it i- perhaps possible, bv mechanical treatment, to improve or 
<aire the patient ; and syphilitic forms, of course, are generally amenable 

1 Op. fit. 



SPINAL PACHYMENINGITIS. 211 

to treatment. Death may occur from exhaustion, and is preceded by the 

formation of bed-sores, and evidences of a typhoid state. 

Diagnosis It is necessary to diagnose spinal meningitis of the acute 

form from myelitis* especially as these are the only two acute spinal mala- 
dies beginning with fever. The pain is much more Bevere in meningitis, 
and is aggravated by movement. The contractures and cramps are cha- 
racteristic of meningitis, and are not connected \\ ith uncomplicated mye- 
litis. Hyperaesthesia, and exaggerated reflex irritability, and the lighter 
grade of the paresis (there rarely being paraplegia, and, if there is, it is 
quite late), are suggestive indications of meningitis, which should prevent 
any mistake. The chronic forms are of slow development, and all the 
symptoms increase progressively after their appearance, the paralysis being 
gradual and connected with contractures of the affected limbs. The para- 
lysis may not be bilateral, as is usually the case in syphilitic meningitis, 
and there is rarely any extension of the disease' to a higher or lower Level. 
In meningitis there are none of the atrophic tissue changes of the myelitis, 
but the chronic form may so closely resemble chronic myelitis as greatly to 
puzzle the diagnostician. The anaesthesia that belongs to myelitis, how- 
ever, is rarely present in meningitis ; and, if it should be, is a late and 
slight symptom. 

Tetanus may possibly be mistaken for meningitis, but such an error in 
diagnosis should be rare, the spasms of the former being much more 
general; and, besides, the temperature variations are entirely different, a- 
tin; thermometric rise in tetanus is unattended by any increase in the 
volume of the pulse ; while in acute meningitis the temperature and pulse 
are those of an inflammatory disease. 

Treatment The acute disease must be met with energetic treat- 
ment. Local abstraction of blood by leeches or wet cups is the first indi- 
cation. Kollet 2 has used the cautery even in the last stages, applying it 
from the nucha to the sacrum, and with good effect. Ohauffard 1 has given 
opium in large doses in the early stages. I prefer, however, suppositories 
of opium or belladonna, which seem always to relieve the pain, and are 
attended by the additional advantage of not deranging the stomach. 
Blisters applied on either side of the vertebral column, iodide of potassium, 
and mercurials (the former in large doses, even to the amount of a drachm 
thrice daily, beginning, however, with a minimum dose), are excellent 
remedies. In chronic meningitis I have repeatedly witnessed the benefi- 
cial effects of ergot, and the notes of the case I present will enable the 
reader to appreciate its immediate and powerful action in a very obstinate 
example. 

B. W., female, aged 24 years, single, domestic; admitted to hospital 
July, l.s7.~>. 

July 6. The accession of her trouble began about eight months ago, 

1 By the use of this term I mean net only general myelitis, hut those Localized 

tonus known as adull and infantile spin.-il paralysis. 

2 Memoiresde I'Aead. Nat. de .Vol.. w. " Rev. Med.. 1842. 



212 DISEASES OF THE SPINAL MENINGES. 

when severe pain in the lumbar region made its appearance. This was 
very intense, and seemed aggravated by the supine position. About ten 
days after this appeared, the abdomen became tender, and there were 
darting pains which extended about the body, radiating from the spine; 
this abdominal tenderness continued for two weeks, and then disappeared. 
She was able, at the end of a month, to "go up stairs, and to move about 
the house." A few weeks afterwards she noticed a loss of power in the 
right leg and thigh, and next in the left ; and, a month later, she found it 
impossible to get out of bed in the morning. She said that her legs were 
hypersesthetic, and spoke of feelings of "pins and needles" in the soles of 
both feet. She says that she thought her trouble arose from a cold that 
she had caught when working in a damp place. All this time her pain 
was (piite intense, and there has been no improvement. She has great 
difficulty in micturition, and is constipated. 

29th. Painted iodine on either side of the spine, and gave her gr. v 
potass, iodid. t. i. d. 

Aug. 17. Her abdomen has been distended by gas for the last two 
weeks. Pancreatine 5ss t. i. d., and low r diet. 

2\th. This treatment has not diminished the size of abdomen. Ordered 
milk, rice, and beef-tea. 

'.Vnh. Lumbar pain very severe. She can hardly move at all, and is 
obliged to use crutches. Injections of tr. assafuetida. Charcoal and water 
fail to relieve the flatus. The abdominal distension is quite distressing. 

31st. To-day another injection of the same kind did no good. Insom- 
nia and great suffering, as the lumbar pain is severe ; prefers her bed, 
and lies on the left side. Chloral hydrate; potass, iodide. Increased con- 
vulsive movements of logs. 

Oct. 9. At times she has localized pain over insteps of both feet, and 
pain on outer aspect of right knee. For the last five days slight numb- 
ii- — as far up as her knees. Legs have "jerked" less for the last fort- 
night ; can move well in bed; very slight power to move right knee; 
frequent desire to urinate; tympanites; some colic, pain less in lumbar 
region. Pulse 120, small and irritable; temperature 101-j 2 ^ . Blisters 
every other night on either side of the spinous processes. 

2 I/A. Abdominal pain lessened ; can move legs more freely ; numbness 
Less. 

.hni. 20, l*7f>. Aeidi nitromuriat dil. has relieved constipation, which 
has been a constant symptom. 

Feb. 7. 5ss. fl. ext. ergot t. i. d. 

[9th. Ergot has had wonderful effect. Patient left her bed yesterday, 

and walked to the front door of hospital (about oil feet) and back without 
fatigue. She steadied herself by taking hold of the bedsteads. Has dis- 
carded her crutches. 

25th. Walks well. 

Mm -<li 1"). (Iocs on! of hospital. 

April 1. Discharged recovered. This patient was seen six months after- 



ise 



\\ ards, and Bhe had had no rela] 

Ergot has ncted equally well in other cases which 1 have treated, and I 
am of ih« opinion that it is more valuable than any other remedy in both 
the acute and chronic varieties of Bpinal meningitis. The actual cautery 
applied every other day should be faithfully used, and in addition we may 
employ setons at the nucha or lower down. Cod-liver oil and generous 



SPINAL TUMORS. 213 

diet are to be prescribed, and every measure i- to be adopted that will in 
any way build up the patient. Should we find vertebral disease, a suita- 
ble brace, or the plaster-jacket should be provided. 



SPINAL TUMORS. 

The growth of tumors in the spinal canal or cord is of far less frequent 
occurrence than in the cranial cavity and brain, but when tumors choose 
this locality their presence is to be much more easily diagnosed. 

The forms of spinal growths are just as numerous as those of the superior 
part of the cerebro-spinal axis. They may be of any of the varieties I 
have named in speaking of cerebral tumors, but the kinds usually met with 
are the following: — 

Syphilomata. 

Fibromata, attached to the meninges, or in the substance of the cord. 

Tuberculous (rare). 

Myxomata. 

Sarcomata. 

Parasitic growths are more rarely found, and the other forms which 
have been spoken of in our consideration of brain-tumors are equally uncom- 
mon. Exostoses give rise to many obscure, but none the less interesting, 
symptoms, while sarcomata are occasionally to be found attached to the 
inner surface of the dura mater or other meninges. 

Spinal tumors are of slow growth, and of course the appearance of symp- 
toms i< consequently gradual and insidious. 

Symptoms. — The first indications are expressions of irritation, and 
as a result there will be localized pain, and various disturbances of motility 
dependent upon the aberration of that part of the cord which is the seat 
of the tumor. Our knowledge of physiology of the cord will enable us to 
appreciate that disturbances in various parts will be followed by symptoms 
of pain, 1 hyperkinesis, akinesis, or muscular contractures expressive of in- 
volvement of the posterior, anterior, or lateral columns, but there is usually 
no such possible localization, as the growth generally impinges upon large 1 
tracts and works wholesale mischief. Compression is followed by -till 
more pronounced symptoms than those attendant upon simple irritation. 
And there may he complete paralysis and atrophy, with muscular contrac- 
tures of the members either of the upper or lower extremities. Should 
the tumor be situated high up in the cord, the muscles at the back of the 
neck may he the -eat of contracture-, and those of the face and neck mav 
even suffer; if the tumor he seated lower down, the bladder and rectum 
may also become involved, as in some other forms of spinal disease. 

Among the early symptoms may be mentioned the constricting band 
which is connected with neuralgic pain- that -hoot down the leg-. These 

1 Reynolds considers that pain in the hack is more intense with carcinoma than 
with tubercular or other growths. 



214 



DISEASES OF THE SPINAL MENINGES. 



indicate irritation of the posterior columns and nerve-roots. Should the 
anterior column and nerve-roots be subjected to the irritating presence of 
a tumor, the consequence of such trouble will be convulsive local spasms 
and increased reflex excitability. Vomiting, dizziness, and pupillary dila- 
tation are mentioned by Jaccoud as evidences of tumor situated in the 
cervical region, while nystagmus and strabismus are also occasional ex- 
pressions of a growth so located. 

The paralysis which follows increased pressure is not always equal, one 
limb being more feeble than another; or there may be hyperkinesis on 
our side, and paresis on the other. 

Unilateral irregular troubles, both of motility and sensibility, are the rule. 
There may be anaesthesia and analgesia on the side opposite the lesion, 
while the paralysis maybe the striking- symptom on the side of the tumor. 
This may be explained by the diagram of Radcliffe, which I have slightly 



is. 30. 



MS S K 




modified. Supposing thai Fig. •">'> represents a segment of gray matter, 

we will consider that S S' represenl sensory fibres of a nerve-root, and 
M A I motor fibres. The sensory fibres decussate, S going to one side of 

tie- body, while S' goes to the other. M and AI' both leave the cord on 
Opposite Bides. A tumor, pressing Upon either lateral half of the cord, 
BUCh as " [," may Bimply paralyze motion on the same side, while sensa- 
tion remains unaffected, and both sensation and motion are intact on the 
other. It deeper pressure is* made, supposing " II" to represenl the 
tumor, n"i only would moftffin be paralyzed on this Bide, but sensation on 
the other, [fa tumor such as "III" should impinge at the decussation 
of the sensory conductor, we might expect total abolition of sensation on 



SPINAL TUMORS. 215 

both sides, while there would be no paralysis of motion. A tumor such 
as "IV" would paralyze sensation on both sides, and motion on one. 

Keflex excitability is ordinarily increased in the Limbs below the Lesion, 
but it is stated that, when tin; inferior part of tin; lumbar region or the 
cauda equina are destroyed, reflex excitability is abolished after a period 
of six days, and that then the muscles begin to atrophy. Jaccoud 1 says : 
" There is here a new application of the law J have endeavored to make 
clear. As long as cerebral influence only is deficient in the Inferior mem- 
bers, the reflex and electric motility and nutrition of muscle- are intact, 
but when the spinal influence is in default these properties are abolished." 

A case which during life seemed to refute this assertion is the follow- 
ing, but after death an additional tumor was found higher up, which might 
have suspended cerebral influence, and still have left a portion of the cord 
capable of giving rise to reflex movements when irritated; but in some 
respects the case still renders what Jaccoud has said somewhat doubtful, 
as the question arises whether the larger tumor did not antedate the 
smaller, and whether the original paraplegia did not take place before the 
growth of the smaller tumor destroyed the cord. The patient entered the 
Epileptic and Paralytic Hospital September 18, 1872, and was examined 
by Dr. Janeway, .Dr. Seguin, Dr. Mason, and myself, and the very 
thorough autopsy was made by Dr. Maxwell. 

P. K., aged 30 years ; occupation, painter ; habits, intemperate. Inva- 
sion of the disease, five years ago. Relations to other diseases, disease of 
the spine. Seat of paralysis, lower extremities. Control of sphincters, 
very poor. Voluntary movements, imperfect. Sensibility, good. Speech, 
good. Hearing, good. 

Patient denies venereal disease, and no indications of it are found on 
examination. He states that ten years ago, after an attack of smallpox, 
he noticed a pain in the lumbar region, slight and irregular in occurrence. 

Accompanying this pain he has had frequent and uncontrollable desire 
to go to " stool," and to make water, but could not do either to his satis- 
faction. This all continued for about five years, when he noticed that he 
was gradually losing control over his lower extremities, and in live months 
was completely paralyzed. 

Says the left lower extremity remained unaffected the longest, and in 
a short time this also became as weak as the right, lias no control over 
bowels, and has but little control over the bladder. Physical examination 
reveals ;i slight degree of right lateral curvature, and a marked prominence 
in lumbar region, and tenderness on pressure :it a point corresponding to 
fifth lumbar vertebra. These signs seem to point to Lumbar abscess, as 
there is slight fluctuation, and the cachexia of patient is decidedly indica- 
tive. 

Both lower extremities are much atrophied, soft, and flabby. Patient 
very anaemic. Prescribed iron and quinine. 

October 9. Patient since examined by Dr. Seguin, who says the ab- 
scess is over a point corresponding to upper third of sacrum, instead of 
last lumbar vertebra, as was first supposed. 



op. cit., p. 852. 



216 DISEASES OF THE SPINAL MENINGES, 

14)7/. At the age of thirteen was struck in the small of the back 
with a stick. No phthisis. At beginning of trouble he had severe 
pains in dorsum of feet, with swelling and short lancinating pains. Pains 
iu back part of the thighs, in loins, and about the sides of pelvis. No 
incontinence of feces. Curvature began about a year later than the 
commencement of paralysis. When limbs were extended, they were 
agitated by clonic spasms, and increased pain in feet. As paralysis 
increased pain diminished, although diminution was not noticed until 
after contracture. In last two years no material change has taken place. 
Pain at irregular intervals, and occasional spasms in legs at night. Has 
had from the first a feeling of coldness, but never any numbness. Volun- 
tary movements at hip-joint quite free. Knees flexible at an acute angle. 
Extension and flexion possible in both knee-joints to such an extent as 
to bring legs at right angles to thighs. No sign of voluntary movement 
below knee-joints. Passive movements free at hip-joints for extension, 
which is considerably restrained at knee-joints. Flexion free, extension 
beyond right angle hindered by tension of flexor muscles of thigh. More 
free at ankle-joints and toes ; the thighs are somewhat wasted, but not 
truly atrophied. Left measures 37^ centimetres ; right, 32 centimetres. 

The legs show extreme atrophy, most marked on right side. Left calf 
measures 23J centimetres; right, 21^ centimetres. The feet are not 
(edematous. The integument over lower half of tibia is apparently hyper- 
trophied, feels clastic, does not pit on pressure ; the appearance as to sight 
is like that of oedema. The bones do not seem enlarged. 

When he urinates he appears to empty bladder at once, but does it with 
difficulty. 

Sensibility decidedly lessened below knee ; slight impairment of feeling 
on posterior aspect of thighs. Sensibility much impaired below knees. 
Impressions of pain are perceived less acutely than normal at top of right 
fool ; less acutely on left foot. Pricking not felt on left toes ; slightly per- 
ceived on right toes. 

Claims to perceive pressure of hands on both feet. On irritating soles 
of feet, slight involuntary movements &re caused in thigh muscles. Legs 
and feel markedly cold. On left foot has ingrowing nail, with ulcerated 
external matrix. The right toe was seat of ingrowing nail, with ulcera- 
tion, some months ago. Lower limbs perspire easily when warmed in 
bed. Very feeble response to f'aradic current on thighs; feeble reaction 
manifested. No response in leg muscles. Lower lumbar region presents 

;i rounded tumor, about 2.V inches in diameter, projecting about an inch, 

and situated wholly over sacrum. '\ ne last two lumbar vertebrae are un- 
naturally prominent. Moderate pressure produces no pain in tumor; lias 

been tender. Several large veins lie over tumor. Tumor elastic to feel, 

and gives an obscure deep fluctuation. 

Deep pressure in left iliac region produces but slight pain. The finger 
reaches a tumor deep in abdomen. Examination by rectum shows a re- 
laxed sphincter; the finger meets with an apparently large promontory of 
Bacrum, which is moderately elastic*; some fluctuation. There is quite 
Burely a tumor involving the anterior surface of sacrum. Pressure of 

finger upon pelvic tumor doe- nol afieel external dorsal tumor. 

Patient remained in the^fcospital for :i year alter this, and finally died 
of e\ bausf ion. 



SPINAL TUMORS. 2 1 T 

Autopsy thirty-one hours after death. Rigor mortis pfi-si jilt off. Ab- 
domen of greenish discoloration. Lower extremities contracted. Left 
foot slightly oedematous ; muscles of extensors atrophied; commencing 
decomposition in superficial veins ; large bed-sores over sacrum. 

Brain P. M. decomposition ; P. M. imbibition along vessels. 

J. nags, Heart, and Liver normal. 

Spleen. — Enlarged and softened. 

Kidneys Left enlarged. Both show advanced 1*. M. changes. 

Stomach and Intestines are apparently normal. The pelvic cavity was 
filled by a moderately firm, elastic, ovoid tumor, extending upward out of 
the pelvis as far as lower border of third lumbar vertebra ; the psoas mus- 
cles flattened, and spread out over its upper and outer border on either 
side. Aorta and infra vena cava raised and flattened by the upper end of 
the tumor ; the external iliac vessels raised from their normal situations 
and course over its lateral borders. All of above-mentioned vessels empty ; 
the ureters are over the upper border of the growth, and are tightly 
stretched and flattened. 

Bladder contracted; fundus raised out of pelvic cavity; muscular tra- 
becular flattened; mucous membrane pale around openings of glandular 
follicles. 

Prostate gland elongated, flattened, and atrophied from pressure. 

Rectum raised and pressed against posterior left lateral wall of bladder. 
The growth had its origin behind peritoneum. 

The tumor has destroyed the whole sacrum, except a small piece of its 
lower end, and a few small thin plates, from here and there, on the surface 
of its posterior attachment ; the fourth and fifth lumbar vertebrae were 
wanting, except portions of laminar and spinous processes; the body of 
third has in its lower border a large concave cavity. 

The tumor was also attached to the lateral wall of the pelvis; the 
articular surfaces of the ilia eroded ; the rijjht most destroyed. During 
its removal large cavities were opened, from which a thin, yellowish, viscid 
fluid escaped, more or less colored with blood. After removal, the tumor, 
with bladder, prostate, and portions of rectum, weighed five pounds; mea- 
sured in long diameter twelve inches, transverse six to seven inches. In 
laying it open on posterior attached surface, the tumor is composed of 
large trabecular and solid portions inclosing areola, which contained the 
fluid above mentioned. 

The surface of the trabecules was covered with small and large villi, 
projecting into the cysts; the general color was yellowish or yellowish- 
brown; in certain portions hemorrhagic. These hemorrhagic patches are 
softer than the yellow "consistency," and there were solid portions, where 
it was quite firm. Microscopic examination showed the histological struc- 
ture of the tumor to be a m\ ■xo-tibroina-cavernosum. 

Spinal Cord A small secondary tumor, about two inches above its 

lower end on left side, behind origin of anterior roots of spinal nerves. 
This tumor is about three-quarters of an inch by half an inch wide, ovoid, 
reddish, and shining, gelatinous, and attached to the " pia mater." The 
Cauda equina has been destroyed, except a short portion of the origin of 
the nerves composing it : the whole cord, but especially the anterior half 

below cervical portion, softened, presenting numerous varicosities. 

Causes. — The existence of the tubercular or syphilitic cachexia, the 
indications of former or coexisting syphilitic symptoms, and the history of 



218 DISEASES OF THE SPINAL MENINGES. 

the patient, may throw some light upon the spinal condition; but, after all, 
Ave know very little about the etiology of spinal or other tumors. Spinal 
growths are rarely found, except in adult life. 

Morbid Anatomy and Pathology. — Syphilitic deposits are found 
in the spinal substance between the meninges and about the nerve-roots. 
The exudation resembles that found in the brain and other organs. The 
site of these deposits is chiefly about the circumference of the cord, and is 
rarely central. Tubercular deposits may affect the entire cord and its 
covering, but have been met with in the majority of instances in the gray 
matter. Jaccoud says that they are nearly always found in the gray mat- 
ter of the lumbar enlargement. Tubercles may be found coexisting in 
the cord and brain. Myxoma are found in the cord much more often than 
in the brain, and are attended by separation of the nerve-fibres and great- 
mechanical destruction. Cancerous growths may and usually do spring 
from the vertebra', and are of a fungoid character. Secondary degenera- 
tions are to be found in certain cases, as well as aneurisms, organized clots, 
cysts, and other evidences of previous disease. 

Diagnosis. — It is not an easy matter to distinguish the symptoms 
which attend spinal tumor from those of some of the other spinal diseases. 
We should bear in mind, however, that the indications are slowly ex- 
pressed ; that the paralysis is irregular ; that one group of muscles may 
be affected at first, and then others ; that the degree of lost power is not 
th<' same on both sides of the body; and, also, that perverted sensation 
is not the same over the two sides ; that, usually, there are contractures 
of the limbs which need not be preceded by atrophy ; and, finally, that 
pain is a symptom which is very constant. 

Prognosis I have never witnessed a recovery from spinal tumor 

unless the character of the growth was syphilitic, and doubt very much 
whether a cure has ever been effected. It is impossible to limit the dura- 
tion of disease which depends so much upon the character of the morbid 
growth. Patients may last for eight or ten years ; or, on the other hand, 
they may live a very short time, should the turn or be cancerous. Death 
usually OCCUrs by pneumonia, uraemia, or some debilitating disease. 

Treatment If syphilis be suspected, we are to give very large 

doses of the iodide of potassium ; or, we may administer the biniodide of 

mercury in combination with this salt. In other states, supportive treat- 
ment or counter-irritation offers a feeble hope of relief. 



SPINAL HEMORRHAGE. 

MENINGE u. ; CENTRAL. 

Synonyms. — Haematorrhachis ; u&matemye'lie (Ollivier). Spinal 
apoplexy. 

Under tlii- head we maj^onsider the effusion of blood into the spaces 
between or under the meninges of the cord, and the effusion of blood into 
i In- substance of t he cord itself. 



SPINAL HEMORRHAGE. 210 

Symptoms. Very often the first intimation of the rapture is a sudden 

loss of power, and consequent inability of the individual to Btand. It may, 
on the other hand, be of gradual development, the symptoms appearing in 
groups, one after the other. The resulting paralysis ia generally complete, 
and the patient loses both motor power and Bensibility, as well as control 
over the bladder and bowels, accompanied by a number of Blowly-developed 
symptoms, with diminution of reflex excitability, although the latter may 
lie exaggerated in some cases should the hemorrhage be small and between 
the meninges. The abolition of muscular power may vary in proportion 
to the gravity of the hemorrhage, and if it be small the patient may ulti- 
mately recover, and eventually present no indications of his loss of power. 
I have never seen a fatal termination before the end of several days, and 
doubt if such could be the case unless the hemorrhage should occur at a 
yery high point, involving a number of the intercostal nerve-root- ; but 
even this is improbable, although Hammond takes an opposite view. Ol 
course much depends upon the site of the ruptured vessel. If the upper 
parr of the cord or the medulla be affected, then an immediate and tatal 
termination is a natural result. Meningeal hemorrhage ifl characterized by 
more pronounced symptoms of muscular rigidity, or by convulsions, which 
may be of a tetanic character. If the hemorrhage has taken place above 
the fourth or fifth dorsal vertebra, it is common to find obstinate pria- 
pism and intestinal disturbances, giving rise to flatus, these resulting 
from paralysis of the splanchnics; if it be extensive, there may be para- 
lysis of motion and sensation from pressure exerted upon the cord, and 
pain and spinal tenderness are also quite marked symptoms, and in un- 
complicated cases there is cutaneous hyperesthesia. There is commonly 
no loss of consciousness in either variety, but when the effusion takes 
place in the medulla there may be conditions akin to epilepsy. In this 
case, however, effusion would be very small, and the region affected would 
be near the circumference. 

Causes Spinal hemorrhage is usually the result of a traumatism, but 

mav proceed from various debilitating diseases and some of the zymotici, 
smallpox playing occasionally a part in the etiology. Alcoholism, and other 
conditions in which the cord is congested, may predispose; or the hemor- 
rhage mav result from the rupture of an aneurism in the vertebral canal, such 
B8 occurred in Laennec's case. It very rarely takes place as a secondary 
accident in tetanus, so that it can be recognized before death ; but at the 
post-mortem examination such pathological evidences may be occasionally 
observed. Traumatisms undoubtedly most frequently produce this condi- 
tion ; and falls, blows upon the back, or concussion following a fall upon 
the feet, enter into the etiology. It may occur in the course of myelitis, 
but again it mav happen without any trace of inflammatory trouble to be 
discovered after death: and. in some instances, there is no history of in- 
jury. Such a case undoubtedly resulted from Budden congestion at the 
menstrual period, and IS reported by ( .ohlanuner 1 : — 



1 Virchow'a Archiv, dan. 1876, and Abstract Medical News. 



220 DISEASES OF THE SPINAL MENINGES. 

*• The patient, a girl of about sixteen years, was suddenly attacked with a 
severe pain in her back between her shoulders, which soon passed over to 
her right, and after a while to her left arm. She also noticed a pain in 
the pit of her stomach, and found somewhat later that she could not move 
her right leg. Having been sent to the hospital, the examining physician 
found complete paraplegia, complete anaesthesia up to the mamillae, and 
paralysis of the bladder, while the reflex action of the lower extremities 
was -till intact ; her temperature was normal, pulse 80 ; did not show any 
brain symptoms, but complained of pain in both arms. A few days after- 
wards the abdominal and dorsal muscles proved to be paralyzed, and per- 
cussion of the spinous processes of the dorsal vertebra 1 caused her pain. The 
pulse was 96 ; her bowels moved only when drastics were given her. A 
slimy discharge from her vagina was noticed. The case was considered 
as hemorrhage into the spinal cord below its cervical enlargement. The 
treatment consisted in local depletion, in the methodical use of the oint- 
ment of mercury, and in the use of drastics. The patient, having im- 
proved in general very little, died from decubitus about a year after the 
attack. The most noteworthy observations made on autopsy are the 
following : About one inch below the cervical enlargement of the spinal 
cord there seemed to be a compressure. A cross section through this 
part showed that its original diameter was reduced very much, and 
that the right lateral column and the adjacent parts of the anterior and 
posterior columns, as well as the gray substance between, were occupied 
by a rusty brown substance of callous consistence. The microscopic ex- 
amination of this proved that it was formed of connective tissue inclosing 
fatty matter, crystals of haunatoidine and a, granulated brownish pigment; 
the vessels in this part had undergone fatty degeneration, their Avails were 
thickened, and contained brown pigment ; no nervous elements could be 
found in this substance ; its entire length was about one-tenth of an inch. 
The adjacent parts, of the medulla were not degenerated by softening ; only 
a few rusty stripes and a yellowish color were noticed on their examina- 
tion ; the whole remaining cord was found to be intact. As no symptom 
speaks for myelitis as a causal element in this disease, it could only be 
caused by an effusion of blood into the substance of the cord : the latter 
probably had been provoked by suppression of the menses, for the heart 
and the vessels, especially those of the spinal marrow, were intact, and no 
injury had occurred to the patient. It is true that she stated she never 
had had her catainenia nor noticed any molimina, in spite of her age and 
bodily development. There were, also, no signs of menstruation noticed 
during her sickness. But there was revealed by autopsy the presence of 
a corpus luteum of the size of a pea, and certainly of a longer standing; 
and a slimy excretion from her vagina was observed a. lew days after the 
attack. These tacts favor strongly the above-mentioned suggestion." 

Morbid Anatomy. — Central : hemorrhage takes place into the upper 
part of the cord more often than in any Other locality, but the lumbal- and 
dorsal segments may also be its seat. The gray matter is naturally more 
frequently the Beal of hemorrhage than the white, and when preceded by 
myelitis or injury it will be generally more extensive than in the latter. 
If the hemorrhage be profuse, we will find that the cord is enlarged at the 

point where the escape of blood has taken place, and that it has a doughy 

feel. Hemorrhage into the meninges may he sometimes associated with 



SPIXAL HEMORRHAGE. 221 

an intracranial condition, the blood escaping from a cerebral vessel, flood- 
ing the ventricles, and passing down into the spina] cavity. Various 
meningeal diseases may terminate in this way, ;is well as Bpinal congestion 

and tetanus, and occasionally spinal tumors and vertebral disease give rise 
to such an effusion of blood. Old cysts have been found in the cord in 
some cases, but their existence is comparatively rare, and when net with 
they present the same appearance ;i- is Been in the brain, though of course 

they are much smaller. In meningeal hemorrhage, the coverings of the 
cord are red and suffused, and perhaps opalescent and thickened, and 
there is possibly some meningitis with sero-purulent collection; the effused 
blood may be found as a semi-organized (dot, and presents, according to 
the time of existence, changes of color of varying depth. Occasionally 
the condition which favors the development of spinal apoplexy may lead 
to cerebral accidents of the same character, and evidences of such trouble 
may be found to coexist. 

Diagnosis. — The symptoms must be distinguished from paraplegia due 
to myelitis, and from those of cerebral hemorrhage, which may, as Brown- 
Sequard has lately shown, be produced. In the former there are primary 
symptoms which I will discuss in speaking of myelitis, and in the latter 
there is usually some affection of consciousness, and some disturbance of 
speech. This latter variety of disease (cerebral paraplegia) is so anoma- 
lous, however, as to have but little weight as a condition to be excluded. 
The subsequent effects of such a hemorrhage, paralysis, contractures, etc., 
may be confounded with several chronic conditions. Among these are 
Bpinal tumors, adult spinal paralysis, and ataxia. The first is connected 
with decided hyperkinesis, is of gradual development, and is accompanied 
by slowly appearing symptoms. Antero-spinal paralysis or adult spinal 
paralysis is ushered in by fever and unattended by any loss of sensation 
or incontinence, and the atrophy is rapid. Locomotor ataxia is symptom- 
atized by increased electric contractility, by no paralysis, and by disturb- 
ance of coordination. 

Prognosis If the hemorrhage takes place in the meninges or in the 

lower part of the cord, the prognosis is perhaps better than if its seal is 
in the cervical or dorsal segments. In the first instance the patient may 
live some time or ultimately recover, but in the latter the probability of 
sudden or early death is almost certain. GrisoUe 1 says : •• Spinal hem- 
orrhage runs a rapid course. A single patient has survived forty days : 
the majority, however, succumb at the end of several days, by suspension 
of respiration. Among others death is hastened or produced by the devel- 
opment of bedsores. Nevertheless, spinal hemorrhage is not necessarily a 

fatal condition." lie refers to a case observed by Crux eilhier. and Btates 
that this i> the only cure of which he has known. Erichsen, 1 however, 



! GrisoUe, Path. Interne, vol. i. p. 659. 
1 On Concussion of the Spine, etc. 



222 DISEASES OF THE SPINAL MENINGES. 

lias reported recoveries which have taken place in eases which were of 
traumatic origin; so the prognosis is perhaps not so bad, after all. 

Treatment. — The early treatment of spinal hemorrhage should con- 
sist of cold applications to the spine, perfect quiet, and rest. Subsequently 
ergot and belladonna will be of great benefit. Blistering and leeches to 
the painful point in the back are next in order, and later on the actual 
cautery is the most serviceable external agent. 



SPINAL HYPEREMIA 223 



CHAPTER VIII. 

DISEASES OF THE SPINAL CORD. 
SPINAL HYPEREMIA. 

(a) SPINAL CONGESTION; (h) SUBACUTE SPINAL HYPEREMIA. 

T\v<» varieties of spinal hyperemia exist: one of sudden origin, and of 
asthenic character, which I prefer to call Spinal Congestion; the other 
of slow progress as compared to the fir>t. and characterized by accumula- 
tion rather than congestion, which I will speak of as Subacute Spinal 
Hyperemia. 

SPINAL CONGESTION. 

This first variety, which has been excellently described by Radclife, 1 is 

not so common as the latter, or at least such has been my experience. It 
is apparently a serious condition, and may somewhat puzzle the incautious 
observer who may mistake it lor some one of the organic disease.-; but it 
has certain distinct features which do not belong to the organic neur 
and I think there should he no difficulty in making a diagnosis. 

Symptoms The following may he the symptoms of an attack Of 

Spinal Congestion. The patient probably attracts the notice of his friends 
by telling them that he cannot get out of bed. that " he feels as if he were 
a lump of lead." or that his " legs and arms are made of wood." lie can- 
not move, and complains repeatedly of his utter weakness : he sighs, and 
may complain that the room is close, and ask to have a window opened; 
he is able to appreciate any warm substances that may be applied to 
the surface, and very acutely feels pinching or the prick of a pin. The 
legs, he says, seem very cold, and he requires extra covering : he lias 
backache and pains, which run down the back of the thighs, but pressure 
• lot- not aggravate the pain in the back, which is only relieved by lying 
Upon the side or belly. His mind i< clear, but he i> restless, suffers for 
want <>f sleep, and is extremely uncomfortable. The functions of the 
bowels are perhaps interfered with, there being constipation; hut there i- 
never incontinence of urine or feces. The patient becomes paralyzed, and 
such paralysis is rather sudden, and may take place during the night, or 
perhaps more gradually after the appearance of pain and the other symp- 
toms just mentioned. Reflex action i- abolished, and electro-muscular 
contractility is increased. 

1 Article in Reynolds' 8 System of Medicine, vol. ii. 



224 DISEASES OF THE SPINAL CORD. 

Radcliffe calls attention to the wasting of the muscles, but I have never 
seen more than the general atrophy which would occur from disease of the 
lower extremities, for the patient may sometimes lie in bed for months 
before he regains the lost power. The duration of the attack rarely 
exceeds six weeks, but there is a possibility of a second attack. The 
paralysis i- generally paraplegic, though it may be irregular in its onset, 
one leg or arm being affected before the other, and in some cases it is 
general. The spinal pain seems to be increased by warmth, and the 
patient will feel the ice-bag to be very grateful after lying upon his back 
for a long time on a warm bed. These pains are as a rule unaffected by 
movement, which is not the case in meningitis. I have never seen bed- 
Bores as a feature of the disease, and for this reason no suspicion of mye- 
litis should arise. 

SUBACUTE SPINAL HYPEREMIA. 

Symptoms The expressions of this condition are very slowly mani- 
fested, and are very often mistaken for those of the opposite condition — 
anaemia of the cord. Tingling and heaviness of the limbs may distress 
the patient, and render him disinclined to take exercise or remain stand- 
ing for any length of time, and much of his want of energy may be mis- 
taken for laziness. These symptoms are especially disagreeable towards 
night in those who have walked much during the day, and there is an 
uneasy, tired feeling, which is only relieved by change of position; and 
the patient seeks in vain for a comfortable place to rest his weary limbs, and 
only finds it when he lies upon his bed or sofa. There may be cutaneous 
anaesthesia, and occasionally hyperesthesia, but these sensory troubles 
are by no means common. There may also be the " constricting band," 
which is so usually suggestive of inflammation, and there are vague 
undefined pains in the thighs, legs, 'and back, which are extremely dis- 
tressing. The temperature is lowered, and there maybe the same op- 
pressed breathing which is such a marked feature of the acute variety. 
1 decided paresis is rare, ami, if it should take place, it is nearly always pa.ra- 
plegiform, and not general, as it may occasionally be in the acute variety. 
Should this he the case, we will find the same impaired condition of reflex 
excitability and normal electro-iiiuscular contractility which characterizes 
the more active variety of spinal hyperaemia. The tendency of the disease 
is to disappear under proper treatment, and in its worst forms is neither a 
grave nor lasting trouble, and should not be Looked upon with alarm. 

Causes. — Women seem to be more subject to the first form than 

men, and this IE probably owing to irregularities of the menstrual condi- 
tion. Uterine conditions* symptomatized by dysmenorrhoea or amenor- 
rhoea, may be, and often are, Its sole causes. Among men, the long con- 
tinuance of the ereel position *flecms to favor the gravitation of blood, and 

hypostatic hyperaemia of (Be spine is thereby induced. A few years ago 
I satisfied myself thai the maintenance of the erect posture for a long-con- 
tinued period resulted in a greal deal of mischief. My investigations 



SPINAL HYPEREMIA. 225 

were much among car-drivers, who were compelled to stand upon the platform 

of the city railroad cars for a period of* from fourteen to sixteen hours daily. 
Spinal congestion, varicose veins, and other vascular changes were common 
and serious results ; and the spinal troubles were only relieved by a long rest. 
Venery, alcoholic intemperance, and malaria are often causes of spinal 
hyperemia; and suppression of any bloody discharge, such as the menses, 
or that from haemorrhoids, will be apt to be followed by more or less 
spinal hyperemia. Among the more serious causes of spinal hyperemia 
maybe mentioned the fevers. The spinal congestions which usher in 
some of the exanthemata are symptomatized by back pains, etc., and do 
not properly come under this head for discussion; but there are conditions 
which play a most important part in the etiology of spinal congestion. 
The malarial cachexia very frequently induces a condition of spinal 
hyperemia which misleads the observer, and the true cause may be lost 
Bight of under the periodic character of the painful exacerbations. This 
we should take into account if there be any suspicion of malarial poison- 
ing. I have seen many cases of very decided subacute spinal hyperemia 
which followed intermittent fever. The disease had become masked to 
some degree, so that no chill was complained of; but the individual suf- 
fered more at some parts of the day than at others, and, in one case of 
this kind, there was some loss of power, which was increased daily at a 
certain hour, and never seemed to disappear entirely. 

Morbid Anatomy and Pathology. — What I have said in speak- 
ing of cerebral hyperemia may be referred to in explanation of the ap- 
pearances met with in spinal congestion. The gray matter will be found 
to be quite dark, and the vessels are usually enlarged. The white matter 
is often of a pinkish hue, and there may be areas of hyperemia which are 
localized; or the suffusion maybe general. Microscopically examined, the 
cord will be found to have undergone very slight changes, and they may 
consist only in increased vascularity, enlargement of capillaries, and per- 
haps some exudation beneath the vascular sheaths. The vessels of the me- 
ninges are engorged, and there are to be observed small ecchymosed spots', 
or occasionally an effusion of serum. The symptoms of the disease resull 
from pressure upon, and irritation of, the nervous elements; and the vio- 
lence will depend upon the site of the most decided hyperemia. The 
gray substance, when subject to pressure from distended vessels, give- i i-< 
to the pain in the back, and cutaneous hyperesthesia, as well as the spas- 
modic movements which symptoinatize the aggravated forms. Spinal 
hyperemia is directly induced by blood delects and disease of other 
organs, and it is favored by the anatomical structure of the part- con- 
cerned. The tortuous course of the veins, and the absence of valveB, are. 
according to Jaccoud, among the latter. The stasis of blood in their inte- 
rior, which follows forced respiration, such as must be caused l>\ violent 
exertion, or by disease of the thoracic and abdominal organs which to 
>ome degree arrests the return of \euous blood from the cnnl. favors 
hyperemia. 
15 



22G DISEASES OF THE SPINAL CORD. 

Diagnosis Spinal meningitis, myelitis, and spinal irritation are the 

diseases with which it may be confounded. 

1st. The spinal pains of meningitis are increased, as lias been shown, 
by movement, which is not the case in spinal congestion, and there is a 
muscular rigidity in the first-mentioned disease which does not exist in 
this. 

2d. Myelitis differs from spinal congestion for the reason that complete 
anaesthesia, wasting, loss of electric contractility and sensibility, reflex- 
excitability, incontinence of urine and feces, and bedsores, belong to the 
former. 

3d. Spinal irritation (anaemia?). The spinal tenderness is increased 
by pressure in anaemia, and there is no cutaneous tingling. There arc 
troubles of other organs, and generally a variable amount of hysteria- 
Hammond alludes to the fact that urinary troubles, when they exist, 
antedate the spinal anaemia, while in spinal congestion they are secondare. 

Prognosis — The chances lor recovery are very good, provided active 
measures are at once taken to reduce the fulness of the spinal vessels. If 
tli** condition becomes a chronic one, even then much may be done to im- 
prove the abnormal state of the circulation. In many cases, however, it 
precedes myelitis, particularly when it takes the slow course which 1 have 
described as subacute spinal hyperaemia, or it may lead to atrophy; but 
this tissue-change is more directly induced by spinal anaemia. 

Treatment The local application of cups, counter-irritants, and 

cold may all be practised; and, in addition, we may use either hydrobromic 
acid (FF. <>, 7), the bromides, or ergot, in full doses; or belladonna (F. 7<>), 
till some of the toxic effects are produced. It is never well to prescribe 
alcohol, strychnine, or iron in these cases, or any other agents which in- 
crease central irritability, and 1 have witnessed disastrous effects from 
their use. The Turkish bath is, I think, one of the best adjuvants to 
these forms of treatment. As a local application to the spine. 1 have 
directed the patient to procure a. strip of adhesive plaster, which should 
extend from the lower cervical vertebra to the sacrum. This is to be 
warmed and dusted with red pepper, and then applied to the back. It is 
a very excellent form of counter-irritant, and may be worn lor some time. 
The cups may he wet or dry, according to the se\ erity of the case, although 
I prefer the former. Should there he any pronounced symptoms, these 
are to lie used two or three times a, week. It must ho home in mind that 

general treatment, such as the re-establishment of fluxes which have been 
interrupted, and the regulation of the functions of the excretory organs, is to 
hi- undertaken as early as possible; for, like cerebral hyperaemia, the con- 
dition is nearly always on.- that is secondary. As an immediate remedy. 

One of Chapman's hags may be lilled with ice-water and applied to the 
back for ten or fifteen minutes at a time, or the ether spray will answer 

the same purpose. 



SPINAL IRRITATION 7 . 227 



SPINAL IRRITATION. 

(spinal anemia?) 

Synonyms Iscb&nie de la moelle. Amende de la moelle. 

The brothers Griffin 1 were the first to describe this Interesting affection, 
and since t lie- appearance of their first paper in the London Medical and 
Physical Journal in 1829, very little 1ms been added to our knowledge of 
this condition, which was fully considered so many years ag.0. 'lie* pa- 
thology of the affection was by the Griffins supposed to consist primarily 
in an irritation of the sympathetic ganglia, and they divided their cases 
into three varieties, viz., those in which the cervical, dorsal, or lumbar 
portions of the sympathetic nerves were involved. In later years other 
observers, among them Hammond, consider the affection due to an anaemic 
condition of the cord, and the last-mentioned author goes so far as to at- 
tempt to localize anaemia of the different columns, ami group- nearly all 
forms of reflex paralysis, etc. under this head. I am disinclined to agree 
with him, not only because I believe that spinal irritation depends some- 
times upon hypenemia, but I think that this condition is due more to a. 
loss or abnormality of cell-functions. I am therefore* disposed to adopt the 
\ iews of the Griffins, and consider •• spinal irritation" to be a condition due 
to a primary perversion of the functions of the sympathetic system, or to 
a secondary ischaemic state, and that in some parts of the cord both abnor- 
malities of circulation exist. - 

Symptoms — The indications of spinal irritation are quite varied, 
but there are several which are distinctly pathognomonic. One of the-- is 
spinal tenderness. If the observer makes firm pressure with his thumb at 
different points over the intervertebral spaces, he may cause the patient 
to wince where a painful point receives the pressure. These tender spots 
may be either in the cervical, dorsal, or lumbar region-, but more often 
the cervical or dorsal. Sometimes the skin is so hyperaesthetic at these 
places that the pressure of the clothing is sufficient to cause the wearer 
great discomfort ; and such patients, be they women, are fidgety and irri- 
table. Pressure made at certain points maybe followed by pain, not only 
in the region pressed upon, but at distant parts; for instance, in one of 



1 Observations on Functional Affections of the Spinal Cord and Ganglionic 
System of Nerves, etc.. by Wm. and Daniel Griffin. London. 1884, 

2 Dr. V. P. Gibney advanced the view before the American Neurological So- 
ciety (session of 1 s 7 7 ) that spinal Irritation was, in the majority ot' cases, a me- 

mingeal affection, and was usualTj the result of injury ofsome kind. In support 

ot' this theory he brought forward a number of cases, all of them of great interest. 
1 am strongly inclined to accept Dr. Gibney' s explanation, but not in its entirety. 

Spinal irritation i> very probabl) due not only to affections of the COrd alone, but 

to the meninges as well, as the symptoms ot' spinal tenderness suggest. That a 

great man) cases arise from disordered functions ot' other organs, there can be no 

doubt, and the history of injur} is very often absent. 



228 DISEASES OF THE SPINAL CORD. 

Griffin's cases pressure made over the dorsal vertebra was followed by pain 

in the sternum. Pain also of a darting or lancinating character follows 
such pressure, and sometimes when the lumbar region is its seat there 
may he twinge- which travel down the crural and sciatic nerves. So, 
too. may there be radiation of pain about the chest when the dorsal por- 
tion of the cord is subjected to this procedure. Pressure over the cervi- 
cal intervertebral spaces produces vertigo, headache, and nausea. With 
irritation of the cervical region, vertigo is quite pronounced. Memory 
is affected, and hysterical manifestations are quite common; while in- 
somnia and headache, disordered vision and facial neuralgia, vomiting, 
and respiratory troubles are all prominent symptoms. The headache is 
connected with soreness of the scalp, and is of a neuralgic character, and 
the fifth nerve is so extensively affected that toothache, faceache, and deep 
orbital pains when they occur, are almost intolerable. As an evidence of 
disordered function of the fifth nerve, there maybe trophic changes in the 
cornea, such as ulceration, and there is in some cases keratitis. Cervico- 
brachial neuralgia may exist in addition to the facial neuralgia, and may 
be either one-sided or bilateral, and pressure made upon the cervical ver- 
tebra 1 may greatly aggravate the neuralgia. Diplopia., amaurosis, and 
other visual troubles are annoying in the extreme, and the intense hyper- 
aesthetic state of the organs of special sense may give rise to hallucinations 
of Bight or hearing. Then' is not rarely photophobia of a distressing 
character, so that the individual is obliged to stay in a darkened room. 
Deafness is an occasional symptom, and ringing in the ears is an indica- 
tion of cerebral anaemia coexistent with the spinal troubles. The gastric 
mucous membrane may be in an extremely irritable condition, so that 
the food is speedily ejected, and with the vomiting there are nausea and 
vertigo. The spinal origin of this symptom may be satisfactorily proved 
by applying a. blister to the painful snot. Various respiratory and cardiac 
irregularities are quite constant accompaniments of spinal irritation. 
Among these are attacks of dyspepsia, angina, palpitation, coughing, or a 
sense ot pressure and discomfort in breathing, asthma, etc. Urinary 
troubles may exist when the morbid spinal condition is situated lower 
down, and often ovarian neuralgia.. Convulsive movements of the legs 
and obstinate constipation swell the list of symptoms. A form ot* paraple- 
gia, usually of an hysterical nature, but sometimes so constant a- t<» seem 

to be dependent upon some organic lesion, occasionally svtnptomat i/.es the 

disease. There is even lowered temperature, though the patient may 
complain of subjective sensations of warmth; but the paraplegia is never 
attended by anj evidences of the real condition which follows myelitis. 

The action of the bladder and rectum is normal, and the electro-muscular 
contractility and reflex excitability are, if anything, increased, and the 
anaesthesia or hyperesthesia, ifil exists, is quite unimportant. 

The following history Was given to me in the patient's words, and is so 

graphic that I consider it worth} of reproduction : — 

\§t year, 1867. There was some cerebral anaemia. Inability to think 

Consecutively, or tO do anything that required looking alter; constant 



SPINAL IRRITATION. 220 

nausea and dizziness; a burning in head and spine, and an occasional 
deep seated and momentary pain in the head; an excessive demand for 
pure air; extreme hyperesthesia of skin ; sleeplessness; worried feeling in 
the ovaries. 

'1<1 year, 1808. Head symptoms slightly improved; body grew weak and 
tremulous; felt as if starving to death, though with good appetite for 
nourishing food. Nausea not constant, but occurring every night between 
nine and ten, and lasting aboUl an hour. 

Zd year, 1869. Mind grew painfully active, it was impossible to stop 
thinking asleep or awake; gradual loss of use of arms and legs, with dis- 
tressing jerkings of latter ; hysterical; light ami sound almost intolerable. 

\tlt year, 1870. Commenced walking after lying in bed seven months. 
Dizziness, sleeplessness, tremor; burning in head and spine continued. 

')th year, 1<S71. Same as fourth year, with some alleviation. 

§th year, 1872. Material changes were more sleep, arrested condition of 
brain, and tremor not constant. 

Ifh year, 1<s7o. Dizziness, which hud been constant from the beginning, 
ceased. Ability to converse, and listen to any amount of reading, attend 
lectures, etc Pain or distressed feeling in head most of time. More de- 
pression of spirits than ever; sleep full of nightmare. Neuralgic pain; 
appetite indifferent; bowels torpid ; menses irregular and over-abundant, 
extremely painful, and prostrating. 

The patient was ~>\) years old, and married. She is in appearance 
anaemic, evidently of a strumous diathesis, and somewhat hysterical. Her 
pupils are dilated, and there is decided muscular asthenia. She cannot read, 
and, when she attempts to do so, there is a peculiar dizziness, or. as she 
very pertinently calls it, a "nausea of the brain." If reading is persisted 
in, the dizziness is excessive, and there is ultimately vomiting. Her head- 
ache is vertical, and some uneasiness is produced by pressure made over 
cervical vertebrae. Her urine is copious and abundant, and contains phos- 
phates. Constipation is persistent and obstinate. At my request Dr. 
Loring examined her eyes with the ophthalmoscope, and found atrophy of 
the left optic disk. 

.Ian. 30, 1874. Strychnia, iron, and phosphoric acid were given, and 
absolute rest required and enjoined: and one month later she returned. 
feeling very much improved. It is possible for her to read two hours at 
a time without being fatigued, and her spirits are very much improved; 
her depression has somewhat disappeared, and she sleeps much better. A 
curious feature of this woman's disease was excessive somnolency during 
the day. and it was often necessary to use violent measures to arouse her 
from her very profound sleep. During the evening she became very ani- 
mated and bright, talking brilliantly upon all subjects, and it w a- not 
until midnight before she again felt a disposition to sleep. In her case 
evidently the menorrhagia was the cause of the anaemia. 

Causes. — The victims of spinal irritation are nearly always women. 
\«T\ rarely men. It may safely be said that nine-tenths i>\' all the cases 
are females. It rarely occurs before puberty, but after thai time may 
make its appearance, and then is generally dependent upon, or asso- 
ciated with, irregular or profuse menstruation. It not rarely begins at 
the menopause, but is more often of earlier origin. Hereditary predis- 
position seems to have much to do with its development. Various mental 



230 DISEASES OF THE SPINAL CORD. 

causes play an important part in its production; care, worry, and over- 
work being among these. Various debilitating diseases, childbirth, and 
bad habits, may be enumerated as additional causes. 

Morbid Anatomy and Pathology. — Spinal irritation being a, 
functional disease, it is impossible to find any post-mortem indications, 
unless they, perhaps, are foci of low inflammatory action, such as thicken- 
ing of the neuroglia, or simple atrophy. 

As to its pathology, I have already expressed my views in regard to 
the probability of both hyperaemic and anaemic conditions as pathological 
factors. It is impossible, I am convinced, to locate the point of irritation 
in either of the columns, and any attempt to do so is an unwarranted and 
impossible refinement of diagnosis. We may approximate its seat by the 
region of tenderness, and the predominance of special groups of symp- 
toms; and this is all that I believe to be possible. Spinal irritation may 
undoubtedly result from — 1. reflected irritation; 2, impoverished blood- 
Bupply; 3, local changes dependent upon disease of adjacent tissues. 

The labors of Brown-Sequard, Bernard, and lately Lauder Brunton, 
have proved most satisfactorily the intimate relation between the sympa- 
thetic and cerebro-spinal systems; and the observations of the former are 
especially valuable because of their pathological bearing. Not only may 
distant organs send irritating impressions to the cord, to be followed by 
vaso-motor stimulation, contraction, and subsequent relaxation of the 
vessels, but the intra-spinal circulation of impure blood may produce local 
irritation, imperfecl nutrition of the nerve-cells, shrinkage of the nervous 
tissue, and oedema of the perivascular spaces. The chain of inhibitory 
ganglia, described in such a, beautiful manner by Brunton. places in close 
relation the different parts of the cerebro-spinal axis, so that, there is 
nearly always a disturbance of several organs when the harmony is af- 
fected. 

The vascular cramp of Nothnagel will account, for various ischaemic 
conditions in certain parts, while circulation in neighboring districts may 
be perfectly normal. Bidder 1 has also shown that complete alteration of 
vascular calibre is impossible, so that at best there is contraction but at 

;i certain point, while the other part of the vessel may be dilated. 

Bidder's experiments also demonstrated that, excitement or exaggera- 
tion of function may exi>t with depressed function at the same time, in a, 
Compound organ. 

It i- therefore reasonable enough to consider that spinal irritation is not 

altogether dependent upon spinal anaemia. 

The production of special symptoms is explained by the involvement 

of sympathetic, cranial, or spinal nerve-roots. The headache may result 

from cerebral anaemia, as may also the mental and hysterical symptoms; 

uhil. the visceral disturbances .arise from sympathetic derangement of the 

1 l>i<- Eteflexe sines der sensiblen Nerven du Berzen auf die motorische du 
Blul 



SPINAL IRRITATION. 231 

abdominal organs. The pain resulting from pressure is due to impressions 
conducted to the over-sensitive centre by the cutaneous nerves. It te 
almost unnecessary to allude to the production of spasms, reflected pain, 
and the numerous dysesthesia. 

Diagnosis. — Spinal congestion, spinal meningitis, and incipient in- 
flammation of the cord, may suggest themselves to the observer. A- to 
the first, differential diagnosis is often impossible, unless there be actual 
paresis. The absence of great spinal tenderness is also an elemenl in 
diagnosis. Spinal meningitis is connected with tenderness, but it is not 
aggravated so much by pressure as by muscular movements. There are 
also present muscular spasms of a painful character. 

Myelitis in the beginning is attended by waist constriction, which is too 
marked to be mistaken; and besides paralysis of motion and sensation, 
there is atrophy, as well as progressive symptoms. The presence of gastric 
symptoms, which are so marked in nearly all eases of spinal irritation, of 
headache, and great languor, a generally depraved physical state, and the 
existence of uterine trouble, should all be taken into account. 

Griffin alluded to several other disorders likely to produce some of the 
symptoms of spinal irritation. These are rheumatism, which is sometimes 
causative of spinal soreness, and various acute diseases, which, however, 
present so many symptoms of a distinct character as to do away with any 
chance for mistakes in diagnosis. The pain of rheumatism is generally so 
severe and absorbing that the patient's mind is constantly directed to it. 
while affections of the joint usually coexist. 

Prognosis and Treatment If the patient be promptly taken in 

hand it is often possible to cure the disease, but I am inclined to consider 
well-established spinal irritation the most discouraging and intractable 
functional neurosis that is to be met with. Commonly connected with 
ovarian or uterine derangement, it defies the best-directed efforts of the 
physician; and, if the factor cannot be removed, the patient becomes a 
confirmed invalid. It is, therefore, proper in all eases to search for the 
cause, and in three-quarters of the female cases it will be found in the pel- 
vis. If there be general anaemia, or some other depraved condition of the 
system, we are to "build up" our patient with cod-liver oil and tonics 
(FF. 57, 43, 7, 8, 9), and a very excellent one is the following: — 

R. Ferri et ammon. citratis, ^iij ; 
Tr. gentianae, §iv. — M. 
Sig. — A teaspoonful in water after eating. 

Phosphorus, either in the form of Thompson's solution ( FF. _ I. 25, 26) 
or the phosphuretted oil, quinine, pyrophosphate of iron, Horsford's acid 
phosphates ( F. 7"2), the svrup of the combined phosphate- ( F. 7.">). are all 
in order. Nutritious food and extract of malt are to be given, and a liberal 

use of stimulants is strongly recommended. Strychnine Bometimea does 

good, ami at others does a. great deal of harm ; and in cases where then' is 
\<t\ severe pain, 1 prefer other remedies. 

Opium in small doses is often of great value, and its effects are innue- 



232 DISEASES OF THE SPINAL CORD 

diate and excellent. External counter-irritation, either by the actual 
cautery applied on the painful points, a blister, or some irritating oint- 
ment, is advised, and if vomiting be present, a blister on the epigastrium, 
subsequently dusted with morphia, allays the irritability of the stomach. I 
have used with success, and would recommend, galvanism (the descending 
current), the positive pole being placed upon the nucha, and the negative 
in the groin. Five-minute seances every day, or every other day, are 
sufficient. 

Galvanization of the cervical sympathetic is an important form of auxil- 
iary treatment. Heat and cold alternately applied to the spine are followed 
by excellent results ; or Chapman's ice-bags, filled with hot water, and 
placed in contact with the spine for fifteen or twenty minutes daily, are 
beneficial. 

Open-air exercise, Turkish baths, massage, all help the patient; and 
.Mitchell's rest-treatment, already described, is one of our best modes of 
treatment in continued cases. 



ACUTE MYELITIS. 233 



CHAPTER IX. 

DISEASES OF THE SPINAL CORD (Continued). 

INFLAMMATION OF THE SPINAL CORD— MYELITIS. 

Synonyms. — Myelitis. Myelite aigue, chronique. 

Definition Inflammation of the spinal cord, usually attended by 

paralysis of motion and sensation below the seat of the spinal lesion, by 
involuntary stools and incontinence of urine, and by absence of reflex ex- 
citability and electric contractility in the paralyzed parts, and a tendency 
to extension upwards, results in death in a very short time from paralysis 
of the intercostal muscles, especially should the pathological condition be 
an acute one. 

ACUTE MYELITIS. 

Symptoms The disease begins rather suddenly, generally with 

pain in the back, which is aggravated by pressure, and an uneasy sense of 
tightness about the waist. These unpleasant sensations may be preceded 
by formication and tingling of the feet, some loss of power, and the devel- 
opment of more or less fever, during which the temperature may be very 
much elevated. These symptoms are followed in several hours, or after a 
day or two, by loss of power in the lower limbs and by an aggravation 
of the spinal pain. The patient will find it impossible to pass his urine, 
and if he is not relieved by a catheter will sutler great distress ; or there 
may be final relaxation of the sphincter, and it may flow from him without 
his knowledge. These symptoms are sometimes presented before a phy- 
sician is called in, and at his visit there may be complete paralysis of the 
lower extremities. The surface of the limbs is cold and utterly devoid of 
sensation, and the soles may be tickled or the muscles pinched without 
any attempt being made upon tin 1 part of the patient to withdraw his feet. 
This reflex excitability, however, is not always lost in the beginning, but 
in;i\ be present when the onset of the disease is gradual, and the patient 
i- entirely unconscious of the occurrence of these movements. It' a heated 
Substance be applied to the back, it will be found that its presence will noi 
be appreciated below the point of spinal inflammation, but when ii is 

passed over the diseased tract the pain is greatl\ increased. A.bove this 
level, normal sensibility exists, and the degree of heat is readily perceived. 

The attention of the physician is attracted by the ammoniaeal odor of the 

urine, which, as has been stated, may flow from the patient without his 
knowledge, and the content- of hia rectum ma\ pass away in the same 



234 DISEASES OF THE SPINAL CORD. 

manner. Hyperesthesia is an exceptional feature, but it may form one of 
the initial symptoms in conjunction with trembling of the limbs. After 
the paralysis takes place, the temperature is lowered several degrees, and 
circulation is very defective. At the end of a week there may be indica- 
tions of the upward extension of the spinal inflammation if it be progres- 
sive, and it is sometimes recognized by the tendency to priapism and the 
distress in breathing, and with these there may be hiccough and hurried re- 
spirations their number perhaps reaching 48 in the minute. Bedsores form 
over the sacrum, and there is every appearance of approaching dissolution. 
The skin becomes clammy, and there may be rigors; while the pulse grows 
small, fluttering, and the voice very weak, and ultimately the patient dies, 
his mind remaining clear to the end. If, however, the structural altera- 
tion progresses upward, it is very probable that the mode of death will be 
asphyxia. As exceptional instances, cases have been recorded in which 
there was myelitis of the upper part of the cord, with complete paralysis of 
the upper extremities, while the lower limbs, the bladder, and rectum were 
not affected, and other equally rare forms are occasionally noted. When 
the dorsal portion of the cord is the seat of inflammatory action, the re- 
spiratory symptoms are immediate, and the breathing becomes embarrassed 
at once. 

The prominent symptoms of this interesting neurosis may be recapitu- 
lated as — 

1. Paraplegia of sudden or gradual origin, attended by anaesthesia 
and analgesia, but usually preceded by dysaesthesia of various kinds, or 
act mil hyperesthesia. It may be accompanied in the beginning, accord- 
ing to Radcliffe, 1 who has observed this symptom in severe cases, by ''un- 
controllable restlessness." Paraplegia is nearly always the form of lost 
power, though in rare cases there is hemiplegia. There may be, in excep- 
tional cases, variations in sensibility, 'the symptoms of anaesthesia being 
absent when the anterior columns are alone partially affected. Again, in 
other cases one leg may be paralyzed and (lie other anaesthetic. The 
onset of the paraplegia may be very sudden, and the disease prove rapidly 
fatal. Jaccoud 9 has seen one case in which the paraplegia developed in 

thirtv-six hours from the commencement of the disease. Eighteen hours 

afterwards, the autopsy revealed a purulent meningo-myelitis of the entire 

Lumbar ami pari of the dorsal segments of the cord. The extent of the 
paraplegia ifl of course governed by the seat and course of the myelitis. If 

the Lumbar portion of the cord be destroyed, the lower extremities, and the 
muscles of the abdomen and Bphincters will be paralyzed; if the myelitis 
extends bo that the dorsal portion arid the cuto-spinal centre are involved, 
the arms are paralyzed, and pupillary changes with irregularity of cardiac 
functions are produced. When the lesion is still higher, and the cervical 

portion of the cord 18 involved, there may be, in addition to all these 

forme of paralysis, various difficulties in swallowing, speech, and respira- 
tion, and the patient di<\s from asphyxia. 



Op. cit., p. 815, 2 Path. Interne, vol. i. p. 81 I. 



ACUTE MYELITIS. 235 

2. Reflex excitability is generally abolished entirely, or impaired to a 
great extent. Occasional exaggeration is Been in the earliest stages, or 
when the myelitis involves limited regions, especially the Lumbar segment. 
Jaccoud says :* " Durant la periode d'exage'ration (hyperkin&ie reflexe) 
le segment lombaire sonstrait a I'influence <ln cerveau manifestait boh action 
propre avec la puissance accrue qu'elle tirait de son isolemenl ; duranl La 
periode d'abolition (akinesie reflexe) cette action propre en spinale est 
aneantie parceque les elements qui en sunt done- sont detruits." 

3. Electric contractility and sensibility are abolished or greajtly lowered. 
The onl) r exception to this rule is when the reflex excitability is increased. 

4. Muscular atrophy as a result of* severance of spinal innervation 
sometimes follows. This may take place in from four to six weeks. The 
atrophy is general, and is of course attended by absence of electro-mus- 
cular contractility and by coldness of the surface. 

5. Bedsores and other evidences of defective cutaneous innervation are 
present. The skin becomes swollen, or there may be at firsl greal dryness 
and redness, or oedema at the points subjected to pressure. A hard, red 
bullous nodule may form, and subsequently break down, and sometimes 
large patches of tissue are rapidly destroyed. 

('). The sphincters ore paralyzed, the urine is intensely alkaline, the 
walls of the bladder being paralyzed, and as a consequence a certain 
amount of urine remains in that organ in a decomposed state, ami rapidly 
induces an alkaline reaction in that which may collect before it i> dis- 
charged. Though Brown-Seqnard is inclined to consider that this con- 
dition of affairs is pathognomonic of disease of the dorsal region, ami I 
infer holds that it is essentially a nervous symptom, I am compelled to 
believe that it is only an intra-vesical change, and occurs in this disease just 
as it may in various local troubles, such as cystitis, prostatitis, or other 
affections in which the expulsive force of the organ is affected, perhaps 
the walls being thickened as a result of local trouble. Radcliffe alludes to 
a reflex spasm of the sphincter ani which occasionally occurs in this dis- 
ease, but this symptom is so exceptional as to need but passing comment. 
The paralysis of this muscle is ordinarily so complete as to be followed by 
the almosl constant escape of softened feces and watery discharges. 

7. Increase of temperature and pulse calls for no special mention. 
Occurring with paralysis of the lower extremities and no loss of conscious- 
ness they can symptom atize bul two acute spinal affections, myelitis and 
meningitis. The spasmodic movements of the Latter disease, however, are 
not observed in myelitis, so that it possesses at Least Borne diagnostic im- 
portance. The temperature varies from the normal standard to 1»»| or 
105 , and the pulse may reach L60. 

8. The constricting band sensation, which is more marked in myelitis 
than any other form of spinal disease, is generally likened by the patient 
to that which might result if a tight cord were tied aboul the body. It 18 

usually located at the waist, and sometime- when it is not complained ol 



1 ( )p. cit., \ el. i. p. .". 1 .'). 



236 DISEASES OF THE SPINAL CORD. 

may be developed by a sharp blow on the back, or by the application of an 
electrode to the spine. 

CHRONIC MYELITIS. 

Symptoms. — The disease sometimes takes a more slow course. The 
paralytic symptoms are much less sudden in their onset, and occur one after 
another, so that the extension of the inflammation may be sometimes 
traced. For some time, perhaps for several months, there may be disorders 
of sensation, such as tingling spinal pain, and the '"constricting band/' 
The perception of pain in the affected limbs, though not entirely abolished, 
is greatly influenced. 

Charcot, 1 Romberg,* and Cruveilhier 3 have called attention to the 
curious mistakes sometimes made by patients in locating painful sensations. 
Pain following the pinching of one leg is referred to the other, and the 
painful impression may take several seconds to reach the sensorium. In 
one of Romberg's patients pressure upon the toe was referred to the hip. 
Cruveilhier's experiments demonstrated that an interval of from fifteen 
to thirty seconds elapsed sometimes before any sensation was excited, and 
that the impression had to be made several times before it was perceived. 
Electric contractility is perhaps increased, and reflex excitability is very 
much exaggerated, and may be followed by very violent movements. 
Thus, when a warm bottle is sometimes applied to the feet, though the 
temperature is not so high as to cause discomfort to a healthy person who 
touches it. the patient's legs will be violently drawn up; this always sug- 
gests a meningeal complication. Dysesthesia are referred to, and pains in 
the joints and bones, especially aggravated by humidity of the atmosphere, 
are spoken of by the patient. The paralysis of motion is muchless exten- 
sive than it is in the acute form and in the beginning; and spasms of the 
muscles of the lower extremity are very violent. Subsequently, however, 
they disappear as the loss of power becomes more complete, and at this 
time there are lowered temperature and electric irritability instead of the 
primary exaggerated condition. The bladder and rectum are subsequently 
affected, and various degrees of deranged function may be noticed. 
One of my patients is obliged to pass his water every ten or fifteen 
minutes, and his bowels an' -<> constipated as to require an injection every 
day. The individual generally loses his power lor sexual gratification if 
the disease is at all advanced, though in the beginning there may be a 
marked disposition to erection. Atrophy takes place if the anterior horns 
be affected. 

Causes The common causes of myelitis are injury, syphilis, acute 

diseases, exposure, and extension of meningeal disease. Falls and blows 

upon the back are the origin of the majority of cases, but I consider 

syphilis i<> have a \<r\ greal Seal to do with even t li<--<', when often it is 

1 Op. .it. 
Manual of the Nervous Diseases of Man, Syd. Trans., vol. i.p. 267, et aeq. 
Aii.iiMinic Pathologique, livre xxxviii. p. 9. 



CHRONIC MYELITIS. 237 

not suspected. Meningeal thickening or acute meningitis undoubtedly 
plays an important part as a mechanical cause ; and in many cases reported, 
disease of the vertebrae has been found to produce the myelitis. Venereal 

excesses, onanism, and continued dissipation are direct causes which 
should not be overlooked. 

Morbid Anatomy and Pathology — When the vertebral canal 
is opened, the investing membranes -lit up, and the cord exposed, it will 
be found to be greatly changed in color and consistency nt certain part-. 
It may be diffluent and of a. pinkish color. Scattered throughout the 
softened portion collections of blood may sometimes be found, and these 
are more often in the greatly altered gray substance, from which the dis- 
ease seems to have started. At other points there may be found evidences 
of slight vascular changes, such as occur in the red Btage of cerebral soften- 
ing. There may be adhesions of tin; meninges to the cortex or collections 
of pus between them. In the more slow form of degeneration (chronic 
myelitis) the process may not be so widespread, Limited areas being only 
affected. As a result of either form there maybe an atrophic condition of 
the cord, or an actual hardness which we shall presently speak of in our 
consideration of sclerosis. The microscopical appearances are the follow- 
ing : the vessels are enlarged, varicose, or broken, and are surrounded by 
effused haematine; the nerve-tubes are swollen, irregular, and disrupted, 
and the axis cylinders substituted by oil-globules or granular debris ; and 
the nerve-cells may have been broken down and become simple granu- 
lar masses of a round or ovoid shape (Gluge's corpuscles). Fat globules 
may be found scattered hero and there if the cord of an advanced case is 
examined ; and the connective tissue may be found to be thickened and 
increased in density. Pus-corpuscles may also be seen. Jaccoud 1 speaks 
of two kinds of myelitis — myelite en foyer and my&lite centred. In the 
first form the meninges will be found to be injected and adherent to tin* 
nervous substance, and the nodules or patches may be several centimetres 
in length or smaller. These foyers are quite distinctly separated from 
each other by healthy (issue, and when one is removed the nidus in which 
it has formed is seen to be in quite normal condition. The anterior 
columns and anterior nerve-roots are often found to be involved; and the 
latter are the seat of " petites nodosites exuberantes." When the dis- 
ease assumes a chronic form, these softened patches may become encysted 
as in cerebral softening. The central form, as its name implies, begins in 
the gray matter, and generally extends longitudinally. 

Diagnosis — It is necessary to exclude spinal meningitis, locomotor 
ataxia , spinal tumors, and spinal congestion. 

Spinal Meningitis. — Wha1 I have already -aid in a previous Article 
renders further consideration unnecessary. 

Locomotor Ataxia — There is no paralysis of motion in this disease, 
but rather an increased muscular activity, which is expressed by the \ in- 
lent manner in which the patient throws out his foot; while in chronic 



1 Path. Interne, ed. 2me, vol. i. p :!!<>. 



238 DISEASES OF THE SPINAL CORD. 

myelitis he drags one foot after another. The neuralgic pains in the ex- 
tremities are absent in myelitis; while in locomotor ataxia they are marked 
symptoms. In myelitis there are none of the paralyses of cranial nerves 
bo commonly found with sclerosis of the posterior columns. 

Spinal Tumors. — The presence of a spinal tumor may sometimes pro- 
duce pressure upon the cord, and give rise to some of the symptoms. The 
slow development of the growth is, however, attended by corresponding 
slowly appearing symptoms, and the paralysis is not complete. The chance 
for doubt as to the condition arises when secondary myelitis results from 
such ;i tumor. 

Spinal Congestion. — These serious symptoms of myelitis are never pro- 
duced by anything but a degenerative process, and there are rarely bed- 
sores, alkaline urine, or the profound disturbances of sensation or motion 
which characterize myelitis. 

Prognosis In every case much depends upon the nature of the 

cause, and the extent of the cord involved. If there be a traumatism, of 
course this gives the disease a serious character, and death may occur in 
a few days. If the myelitis result from pressure from diseased and dis- 
placed vertebrae, the result, though more distant, is equally bad. Very 
few cases recover entirely from chronic myelitis, and in those that do, the 
Lesion must either be due to syphilis, or be xcvy limited. 

Treatment. — Counter-irritation, cold, and ergot are useful in the 
early stages of the acute disease. The former may be produced by the 
actual cautery, but care should be taken not to burn extensively, as the 
tissues are too ready to slough. Ice-bags maybe used, and the patient 
should be laid on a water-bed, and kept as clean as possible; the thighs 
and nates being washed occasionally with salt and water, or with hot and 
cm Id water alternately. The iodide of potassium, with belladonna, should 
be given internally (F. 71). Should die case be one of slow development, 
1 prefer the use of ergot in half-drachm doses thrice daily; or we may 

USe the bromides (F. 14). 

The sesquichloride of iron (F. 75) seems to have enjoyed deserved 
popularity in England, and it is preferred by RadcliiFe to the iodide of 
potassium. In one case I obtained very excellent results with the tincture 
of the chloride of iron. Phosphorus and cod-liver oil. those valuable 

builders of healthy nervous tissue, may be employed here with every hope 

that they will do good. In chronic myelitis they are especially service- 
able, and, later on, small and frequent doses of strychnine are, in addition, 

useful. There are forms of auxiliary treatment which not only increase 
the comfort of t he pat ient , but go Par towards ameliorating his disease. 

One of these is the assumption, if possible, of a position which shall favor 
the determination of the blood from the spine. Brown-Se'quard has re- 

commended thai the patient should lie upon his side or belly, with his 
lege somewhat lower than the rest of the body. I have found that wash- 
ing out the bladder with a dilute solution of carbolic or nitric acid, or 
chlorate of potash, prevents the disposition to cystitis which there very 



ANTERO-SPINAL PARALYSIS OF INFANCY. 239 

often is in myelitis. Warmth of* the limbs, established by wrapping them 
in cotton butting, witli a covering of oil-silk, or the new India-rubber 
tissue-paper, prevents contractions, and stimulates the cutaneous circula- 
tion; while application of the faradic current, and the employment of mas- 
sage, help the patient to a great extent. The electric brush should be 
used faithfully every day, and it is better that the physician should make 
his own electrical application, than trust it to a nurse or attendant. 



ANTERO-SPINAL PARALYSIS OF INFANCY. 

Synonyms — Paralysie essentielle de l'enfance (Rilliet and Barthez); 

Infantile Paralysis (Radcliffe, Volkman, and others); Paralysie atro- 
phique de l'enfance, Organic Infantile Paralysis (Hammond); Infantile 
Spinal Paralysis (Seguin); Spinale Kinderlahmung (Heine;. 

Definition This form of paralysis may be described as a condition 

usually characterized by a primary febrile stage, a secondary paralysis 
generally of the lower extremities, and a tertiary atrophy. The j aralysis 
is incomplete, as sensibility is never lost. 

Symptoms The disease is marked by a febrile onset of greater 

or less severity, attended by restlessness, malaise, and pains in the joints 
or back, and there may be rigors; or in some instances the loss of motor 
power is preceded by one or more paroxysms of convulsions. This febrile 
State is by many mothers mistaken for "teething," "worms," or other un- 
important childish troubles, and it is not till the development of paralysis 
that any alarm is created. This symptom appears within two or three 
days from the beginning of the fever, and may take place at night. The 
only condition of disturbed sensibility is one of hyperesthesia, which, 
however, is not a constant symptom. 

Sinkler 1 has collected a number of cases in which he has noted the 
form of invasion of the disease. He found that the paralysis took place 
suddenly, that is, with prodromata in but of L08 cases, while Mr-. 
Jacobi 2 noted this form of invasion in 1 2 of If).'! cases that Bhe had col- 
lected. The modes of onset are the following: — 

1. The child, while playing, suddenly drops palsied. 

2. The child may be paralyzed at night. 

3. Fever, but no convulsions; rapid loss of power. 

1. Convulsions, followed by sudden paralysis. (Sinkler reports but 
one case of this kind, and hut two in which convulsions followed the 

paralysis.) 

5. The paralysis preceded by one of the exanthemata, or by whooping- 
cough. 

1 Clinical Lecture, Med. and Surg. Reporter, March 1". Is77. 

2 Am. Journ. of Obstetrics, May, 1874. 



240 DISEASES OF THE SPINAL CORD. 

('). Gradual development, perhaps limping at first, and afterwards com- 
plete paralysis, but QO acute symptoms. 

In this exceedingly valuable lecture, Sinkler throws much light upon 
the symptomatology of the disease, and gives the details of a classical 
cas< . 

The paralysis may take the form of hemiplegia, or it may affect the 
voluntary muscles of all four extremities, and some of those of the trunk ; 
but the facial muscles, as a rule, escape. After a short time there is a 
return of power in many of those at first involved, and but a, small number 
of muscles (notably the anterior tibial, peroneal, and others of the leg and 
thigh) remain powerless. 

The temperature of the paralyzed muscles is much lowered, and Ham- 
mond has seen a difference of from eight to ten degrees between the 
affected and normal sides. The bladder and bowels escape the paralysis, 
and their functions are consequently unimpaired. 

Muscular contractility is lost with the commencement of the paralysis, 
and the faradic current will rarely produce contractions. Such, however, 
is not the case with the galvanic, except in extreme instances, or when 
the case is one of long standing. So far there are rarely any evidences of 
atrophy or contractures of the paralyzed muscles, but it will be found now 
that certain muscles at first affected begin to regain their lost functions, 
while others become atrophied and utterly useless. Even the galvanic 
current fails to stimulate them ; and at this period, which may vary from 
four to five weeks to six months from the beginning of the disease, there 
may be deformities and muscular contractures, which may result either 
from the weight of the body upon the affected limb, or from the antagonism 
of non-paralyzed muscles; butVplckmann 1 considers that this incapacity of 
the Limb to support the superimposed loud is of much greater importance 
;i- ;i cause of deformity than the mere antagonism of the unaffected muscles. 

These deformities may take place as lateral curvature of the spine, tali- 
pes. ;iinl other distortions which appear as various muscles are paralyzed, 
or, if there be shortening of the limb (which is by no means uncommon). 
as a Consequence of reduction in the length and si/e of bones which have 
become atrophied. The deformities that may result from the disease under 
consideration are of a primary^ and of a. secondary or compensatory nature. 
The primary forms are those which are seen as talipes of both kinds, and 

result from Loss of sustaining power of the muscles. The compensatory 

Consist in spinal cur\ at ures, such as lordosis or scoliosis.' 2 Tim skin is 
Usually blue and Livid, and the temperature is much below that of the 

healthy Limb. These deformities rarely disappear, hut continue through 

life, which i> in no way shortened by the disease. The following cases 
m; i \ he presented to illu-l rate I he :i 1 1| m ;i r.i nee and heha\ ior of t he disease. 

The first case is somewhat anomalous, as there were two forms of para- 

1 Sammlung Klinischer Vbrtr'age, 1 1 » • 1 1 i. L870. 

2 Produced bj attempts to restore disturbed equilibrium. 



ANTERO-SPINAL PARALYSIS OF INFANCY. 241 

Lysis; the primary attack being hemiplegia, and the secondary para- 
plegia :— 

Case I Robert B. (a seventh-month child) was sent to me by Dr. II. 

G. Piflard, of this city. During September, 1876, he became feverish, 
and, after two days, during which he was confined to bed, he had a general 

convulsion. Before his fever he had eaten a greal quantity of cherries, 
and bis mother supposed bis illness to be due to this cause. The mother 
stated that the convulsion lasted three and a half hours. He became para- 
lyzed two days afterwards, the right arm and leg being affected ; but 

two days after this be could use 1 even these limbs. A few day- subse- 
quently lie went out to play, but came back feeling out of sorts; and, after 
a few hours' fever, another spasm took place. Within the next thirty-six 
hours both legs were paralyzed, so that be could not stand. Towards the 
fir>t of November be regained some power, and can now stand when hold- 
ing a chair. 

Present Condition He is a puny boy, about five years old. and is badly 

nourished. He has no voluntary power over lower extremities, but can 
move the arms perfectly. The legs are both very much reduced in size, 
and the muscles are flabby and atrophied. The peronei, solei, and ante- 
rior tibial muscles are reduced in size, and have lost their electric con- 
tractility. He perceives pinches, and changes of temperature, and the 
" wire-brush" produces much pain. The skin is cold, mottled, and dry, 
and here and tbere is dotted with patches of scurfy eruption. 

Cask II — Annetta F., aged 10 years. About three years ago she be- 
came quite ill after a sleigb ride, and it was supposed that she had k4 caught 
cold." Her feverish symptoms were quite decided, and she was slightly 
delirious. After several days she seemed to improve slightly, but on 
awaking one morning it was found that she was paralyzed and unable to 
rise ; and sbe complained of intense backache and tingling of the limbs. 
which, however, were of very snort duration. About two months after this 
she began to recover the use of her arms, but the legs were more fully 
paralyzed; and it was several months before sbe began to move her 
toes, and finally make feeble movements of a more extended character. 
The muscular contractions of the flexors were performed more easily than 
movements requiring extension ; and, after a time, she attempted to walk, 
but at first this act was impossible. During the next year she was obliged to 
use crutches, and needed the assistance of her nurse. When I saw her. 
there was talipes equinus varus of the left foot, while the right seemed to 
be but little affected. Flexion was possible, but extension of the leg or 
loot was beyond her power. There was some relaxation of the ligaments of 
the knee-joint, so that when I made extension I caused the tibia to form 
an obtuse angle with the femur, so that there was some anterior curvature. 
Her gait was peculiar, ami she swung the left leg. bringing it down with 
a jerk. The skill covering the left leg was dusky and mottled, and seemed 
in close contact with the tissue beneath; and the surface-temperature was 
Beveral degrees below that of the other side. No rectal trouble. 

Case III. — A girl sent to me by Dr. Lockwood, of Norwalk, had pre- 
sented, among other symptoms, mitral disorder, fever, general paralysis, 
residual paralysis, paraplegia, and pararj sis and atrophy of the right deltoid, 
which cannot be made to contract when subjected to either current. Right 

leg more affected than the left. 

Case IN' A girl lOyeara of age. At the second year after a fall Bhe 

became feverish, was delirious, and took to her bed. Then' wa- genera] 
1G 



242 DISEASES OF THE SPINAL CORD. 

paralysis of the right leg and thigh ; but after three months there was im- 
provement, except of the leg, which remained paralyzed. There are now 
a pronounced talipes varus, complete atrophy ot the anterior muscles, and 
utter loss of electro-muscular contractility. She has used various forms of 
orthopaedic apparatus without relief. 

Case Y. — Frank X. C, 4 years old, a stout, rugged boy, enjoyed 
good health until January, 1877, when he contracted scarlet fever, with 
albuminuria as a result. From this he recovered, but in August he again 
fell sick with what was pronounced to be rheumatic fever. There were 
high temperature, some diarrhoea, which lasted for a number of days, pain- 
ful joints, and loss of power in both lower extremities. The power re- 
turned in the right leg, so that by the middle of September (three weeks 
from the invasion of the fever) he had control of that member. The left 
remains powerless, and there has been slow atrophy. The extensors of 
the leg and foot are now powerless, and there is decided atrophy of these 
and the posterior tibial, adductors of the thigh and anterior muscles. The 
knee-joints are quite weak, and there are projections on the inner side of 
both knees. He is knock-kneed, no eversion or inversion of feet, but 
there is slight talipes of the left foot. 

Cask XI Mamie W., <*> years and 1 month old, always was a nervous. 

excitable child. Has had several convulsions in her life of an epileptic 
character, without any after-effects, or apparent coexisting disease. In 
July last she had whooping-cough. On September 4th she was taken 
with colic, malaise, and convulsions, during which the body became rigid, 
and she frothed at the mouth. These convulsions appeared at 5 P.M.. 
and lasted until midnight. She was unconscious all the time. At 7 P. M. 
the corner of the mouth became drawn up by spasms. She had fever dur- 
ing the following day and lor a number of days. Did not make any 
attempts to move for a number of days, and for twelve days she could not 
speak. She was found to be generally paralyzed, ami after a. short time 
the arms recovered their strength, but the legs began to lose their size and 
shape, and became smaller than they were before. Her mental condi- 
tion is defective (five weeks after 'attack). And, though there is no 
impairment of bladder or rectum, she does not call attention to her wants, 
but defecates and urinates in her clothing. Power of upper extremities 
good. The legs are cold and mottled; there is slight talipes on both sides; 
and great wasting of the tlexors of the feet, especially of the right. Faint 
conl ructions are excited by the strongest faradic currents, but she can 
move her toes \ery feebly, but not Ilex the foot. She has control over 
the thighs. Both feet are slightly everted. There is redness of the skin 
covering the light knee, but no jiain ; no pain in back; slight impairment 
of sensation, hut reflex irritability not embarrassed, as was demonstrated 

by pinching; pupils moderately dilated. 

The muscles of the leg are more often ailed ed than those of any other part. 
In nearly every instance the tibialis anticus is paralyzed, and in is of the 
23 examples I have noticed this muscle was affected. The peroneu$ ter- 
fins, longus; extensores longi digitorum, proprius pollicis; and the 
jir.rons longi digitorum, and longus jtolliris, are usually affected. The 
deltoid is paralyzed more Purely, and of the cases I have enumerated there 

Were DU1 tun in which this muscle Was affected. The muscles of the up- 
per extremities are Beldom in\<>l\e<l in comparison with those of the leg. 

;i!nl those that air usually paialwed are the flexors of the hand. Though 



AXTERO- SPINAL PARALYSIS OF INFANCY. 243 

the muscles of the trunk may be sometimes involved in the early paralysis, 
it is extremely rare that we find any residual paralysis of any of them. 

Causes The etiology of the affectum is anything but clear. Expo- 
sure and bad or insufficient food are supposed to account for it. just as they 
do for man}' other diseases of the same class. It is a significant fact that 
more of these patients belong to the lower walks of life than to the higher, 
and that the children of the destitute poor who come of drunken parent-. 
and are "knocked about" and half-fed, are those who are generally the 
victims of the disease. As to age, Sinkler has found that 84 of IQ8 cases were 
between the ages of six months and three years, and thai half of this Dum- 
ber were males. Duchenne 1 holds that two-thirds of the cases begin before 
the second year, which view 1 am disposed to take. Warm weather seems 
to favor the development of the disease, and in nearly two-thirds of Sink- 
ler'- eases the disease began in the months between May and October. 
Cases have been reported in which the exanthemata have preceded the 
paralysis, and varicella, measles, ami scarlatina may be mentioned among 
these; but it is probable that in the majority of such cases sclerosis not 
limited to the anterior columns has been the central condition. 

Morbid Anatomy and Pathology — We are indebted to Charcot 1 
and Jofiroy, Duchenne, 3 Echeverria, 4 and others for reports of autopsies 
and microscopical examinations, and as the result of their investigations 
the following appearances may be looked for. 

In the early stages of the disease there is probably a condition of sub- 
acute myelitis, with softeningand destruction of nerve-elements, etc. This 
is confined exclusively to the anterior horns. Some of the nerve-cells of 
this portion of the cord are sometimes tilled with granular pigment deposits, 
while others are disorganized and broken up. The nerve-tubes of the 
anterior roots will be found shrunken, the myelitic absent, but the axis 
cylinder is nearly always intact. 

In other cases of longer standing there are evidences of atrophy of the 
anterior horns, perhaps amyloid degeneration, and sometimes sclerosis. 
The nerve-cells are found in an atrophic condition, or absent altogether. 
The white matter of the anterior and lateral columns is not rarely the 
Beat of such degeneration, and proliferation of the connective tissue is 
sometime- found. In 25 cases, collected by Seguin, 5 the constancy of the 
Lesion i- very clearly shown. 

The anterior horns together were affected in 
The right anterior horn alone was affected in 
The left 

Both affected in 

Sclerosis of antero-lateral columns (chiefly) 

matter .......... 1 :) 

Tubercules and blood-clots . . . . . .-_'•• 

Meningitis and meningeal congestion . . . . 2 

1 De 1' Electrisation localisee, 3d ed., Paris, 1872, p. tir. 

2 Aivhiv. de Phvs.. tome iii. 1870. ■ [bid., tome i' 

4 Reflex Paralysis, etc., p. 29, New York. 18 
■ Spinal Paralysis, etc., pp. 12 13, 











i i case 










l case 










i case* 


nd 


otlu 


r w 


lite 





244 DISEASES OF TIIE SPINAL CORD. 

Dumaschino 1 and Roger, Corneil, 2 Clarke, 3 Charcot, 4 and JofFroy have 
added many histories to those given to the profession by the early writers, 
and it is now well settled that the anterior horns and lateral columns are 
the seats of the central lesion. 

Rosenthal 5 considers that the primary cause is dilatation and thickening 
of the vessels, and does not believe that the morbid process begins by 
degeneration of the nerve-cells. Notwithstanding the appearance of well- 
defined lesions in nearly every case, there are occasional examples of the 
disease where no central changes are to be found. Ketli 6 reports one of 
these in which extensive muscular alterations were visible, but not the 
slightest indication of central disease. Elischer' examined the muscles, 
which were seen to be the seat of both fatty and colloid degeneration. 
The sareolemma and nerves were not altered. In the striated muscles, 
instead of the single normal cell-nucleus, there were seen three or four 
granular cell-nuclei, which seemed to be at the same time enlarged, and 
contained two or three, or even more nucleoli. The contractile material 
was diminished, so that it did not fill out the sheath, but drew away from 
it. This atrophy was so great that at the upper and under part of the 
spindle-shaped cell-nucleus of the sheath there was hardly to be found a 
breadth of .002 millimetre of cross-striped contractile muscular substance. 
Ketli thinks that these changes in the muscle without central disease point 
to the peripheral nature of the affection, in which opinion lie has but lew 
followers. Lesions of peripheral nerves have been found by various 
observers. Rinecker 8 reports an autopsy, made by Forster, in which 
these nerves were found to be thin, shrunken, and greatly degenerated. 
The hones and muscles present appearances which are perhaps more inte- 
resting thai) those of the cord. 

The muscular fibres are at first found to be reduced in size, and subse- 
quently the transverse stria' gradually disappear, while the longitudinal 
fibres become more marked. There is a marked increase in the connective 
tissue, and next a fatty degeneration, the oil-globules taking the place of 
the normal muscular tissue, and finally nothing remains hut the connective 
tissue and fat, which latter disappears, leaving the sareolemma hound 
together by connective tissue. 

The accompanying cuts, from Duchenne, show the changes that take; 

place. 

The bloodvessels running to the atrophied muscles are often of smaller 

size than they should he, a.nd sometimes are the subject of atheromatous 
degeneration. 

The bones also undergo atrophic changes, becoming friable and thin, 



' (;.,/. Mr I. de Paris, 1871. 2 [bid., 1864, p. 290. 

■ Med.-Chir. Trans., vol. ii. L09, |>. 249. 

i op. c it. ^ r> Quoted by Fox, op. cit., p. 290. 

a II, id. 7 [bid. 

• Jahrs. fur Kinderheilkunde. 1871, ■"> Hefl I. 



ANTERO-SPINAL PARALYSIS OF INFANCY. 



245 



Fig. ?> 







: 

t ; . 1 





a. Normal fibre. 
A. Represents the normal fibres with well-marked transverse stria;. B. The transverse stria 
are not quite so distinct, but the longitudinal fibres are well marked. 



Fig. 32. 



Fig. 33. 




- ■ i 



a. Fat cells, b. Interstitial fatty deposits. 

The stage of fatty degeneration. A. The lon- 
gitudinal fibres are only seen, and there is a de- 
posit of round and oval adipose cells and oil-glo- 
bules. B. Undulations of longitudinal fibres. 





a, a. Fat molecules. 

The progressive fatty degeneration and 
the disappearance of longitudinal fibres. 



-■ 



Fig. 34. 

" - : r* - - ■ 



This illustration represents the final stages, in which it will be seen thai the muscular fibre baa 

Lost Its i den lily, and at la>[ there is an ah-cncc 6Ven Of oil-globnle8. 

and occasionally the scut of fatty degeneration. The cartilage covering 
their articular extremities is roughened, and in some place- detached. 

Though some observers have maintained the peripheral origin of the 
disease, the large majority have adopted Heine's original dews advanced 



246 DISEASES OF THE SPINAL CORD. 

in 1840, an<l endorsed by Dnchenne in 1855. The almost general opinion 
thai the disease is of central origin lias been conclusively proved, I think, 
by the large number of autopsies, the most valuable of which have been 
made in late years. 

Westphal's views in regard to the existence of trophic cells, which were 
also adopted by Dnchenne, certainly receive decided confirmation in the 
constant atrophic processes which are connected with degeneration of the 
Cells of the anterior horns. 

Thai it is not a disorder dependent upon the sympathetic system has 
been proved by the utter absence of any diseased condition either of the 
ganglia, or the nerves. 

Diagnosis. — The existence of febrile symptoms, and the secondary 
complete paresis which changes its character and is finally confined to a 
tew muscles, the unimpaired sensibility, and the rapid sequence of atrophy 
and deformities give this disease a distinct character which does not ad- 
mit of any mistake in diagnosis. Forms of reflex irritation, such as asca- 
rides, adherent prepuce, and like peripheral conditions may produce some 
of the symptoms, but their non-progressive character, and disappearance 
with the removal of the cause, should make the possibility of an error very 
remote. 

Prognosis Much depends upon the behavior of the muscles under 

electrical stimulus. If the least response either to the galvanicor faradie 
currents can be recognized, the chances are extremely good, and it only 
remains for the physician to be patient and attentive. In regard to dura- 
tion and its bearing upon prognosis, I may state that many cases have 
been cured even after deformities have taken place. Klopsch, 1 of Bres- 
lau, reports several of these cases. In one there was shortening of the 
thigh and deformity of the pelvis, as well as other serious troubles. Much 
of the hope of cure, however, depends upon the care taken in the treat- 
ment. 

Treatment The most active and useful agent in the therapeusis of 

this disease is undoubtedly electricity, either as galvanism or faradism, ap- 
plied to the muscles. The treatment of the central lesion is also of im- 
portance, and it i- advisable to begin an energetic, course of bromides and 

ergot, with the actual cautery, before the atrophic condition commences. 
After this the central disease is very difficult to manage. Heine recom- 
mended Btrychine (FF. 8, '•>. 10, 32, 40, l"2), which, in young children, 
may be given in doses of i^th of a grain, and afterwards increased. Cod- 
liver oil and sea-air, good (bod, and tonics are of as much importance as 

;in_\ i hing else. 

When we come to llie treatment of the paralyzed muscles, we may try 

electricity, massage, hypodermic injections of strychnine, and the applica- 
tion of heal and cold. [f the faradie current be found to be incapable of 

producing contractions of the paralyzed muscles, we must make use of the 
1 UUsburger'fi Prize Essay, Am. Journ, ofObstet., L870-71. 



ANTERO-SPIXAL PARALYSIS OF ADULTS. 2 \ 7 

galvanic current. From ten to thirty 1 cells of any good galvanic battery 
should be employed, and the electrodes must be covered with sponge or 
cloth. When the positive electrode is placed in the groin fit' the legs are 
paralyzed), and the negative over the muscle or muscles paralyzed, a con- 
traction may be seen ; if such docs not take place, the current may be 
slowly intermitted by proper apparatus, or by simply removing the sponge 
from the surface and reapplying it again. If the current be too strong, or 
if the application be too protracted, we may be disappointed, for the small 
amount of electric irritability that exists may be quenched before an ap- 
preciable contraction is perceived. It is therefore better to use a currenl 
of low tension. If we are gratified by the appearance of a contraction, we 
should produce two or three more and then stop for the day. By increas- 
ing the muscular stimulation little by little each day, we may finally create 
powerful contractions with a minimum current, and after a short time we 
may substitute the faradic current. It is of great importance that muscular 
relaxation should be produced during the use of electricity. I may repeal 
what I have already said, and add that a tired muscle naturally responds 
less perfectly to electric stimulation than one which is unimpaired. If 
massage is used, it is well to knead and rub each muscle every day. 

Should electricity fail to relieve the contracted condition of the limbs, 
which may be present, we may avail ourselves of the knife. Tenotomy 
is often of service, but it should not be prematurely resorted to, but left 
as a last resource when all other remedies fail. 

Volckman speaks in glowing terms of the use of Junot's boot, which, 
with the rubber muscle of Sayre, and the plaster bandage, is a useful form 
of treatment in these ancient cases. The paralyzed limb is placed in the 
hoot and the air exhausted, so that a determination of blood to the part 
shall be induced. 



AXTElxO-SPIXAL PARALYSIS OF ADULTS. 

Synonyms Acute anterior spinal paralysis. Subacute general ante- 
rior spinal paralysis (Ducbenne). Spinal paralysis of adults (Meyer, 
Charcot, Gombault). Myelitis of the anterior horns (Dujardin-Beau- 
metz, Seguin). Acute spinal paralysis of adults (Petitfils). Anterior 
poliomyelitis (Erb, Kisenlohr). Acute anterior poliomyelitis (Kussmaul). 

Definition. — A myelitis of the anterior horns of the spinal cord, either 
Symptomatized by an acute invasion attended by fever, and followed by 
Sudden paralysis, or by the gradual appearance of the paralysis which be- 
comes complete and next partially disappears, leaving certain muscle- 
affected; unattended by loss of sensation, or vesical and anal trouble. 

Symptoms. — 1 am indebted to the little memoir of \)v. E. C. Seguin 
for assistance in the preparation o\ this article, and for the report of a 

1 It will rarely be found necessary to use this Dumber, and it i> advisable to 
begin with tin. 1 weakest currenl that will provoke contractions. 



248 



DISEASES OF THE SPINAL CORD. 



case which afterwards fell under my observation when I followed him as 
visiting physician to the Epileptic and Paralytic Hospital. Dnchenne 1 
first called attention to this form of paralysis as early 
Fig. 35. {l s 1853, and recognized its identity with infantile 

paralysis. In 18G3 Charcot 2 was struck with the 
similitude between the two diseases, and in 1872- 
73 and later years Gombanlt, 3 Dnjardin-Bean- 
metz, 4 Petitfils, 6 and Bernhardt 6 have presented 
cases, and decided the fact that infantile paralysis 
had an analogue in adult life. Gombanlt brought 
forward the first case with an autopsy confirming 
the theory enunciated by Duchenne. In this coun- 
try Hammond 7 has written quite fully, and later the 
admirable little works of Seguin epitomize all that 
has already been brought forward. The first case 
seen by Seguin 8 lias since fallen under my observa- 
tion, and from his published notes I copy her his- 
tory. 

Female, unmarried, aged twenty years. Admit- 
ted to the Epileptic and Paralytic Hospital, Black- 
well's Island, service of Dr. E. C. Seguin, Novem- 
ber, 1871. Patient presents a paralyzed and ex- 
tremely atrophied left leg, and gives the following 
imperfect history : The trouble began nine mouths 
ago, suddenly during sleep, with painful contrac- 
tions : she then gradually(?) lost power in the left 
leg: no other limb affected. The patient cannot state how long a time 
elapsed between the first symptom and the discovery of palsy. She adds 
that, on the day before tin; attack, her left leg felt quite cold and a little 
numb ; and that her menses were suppressed. No cause is apparent — no 
hereditary influence, no injury. 

Examination: Left foot is drawn up in moderate pes eqirin/is, with 
inward inclination. No voluntary movements below the knee. The 
patient's answers to the sesthesiometer test are unreliable ; sensibility to 
painful impressions is somewhat impaired, that to temperature preserved ; 
tickling i- fell equally on both feet. Pressure shows tenderness over the 
lumbar vertebrae; no spontaneous pain. The right calf measure- 26.9 c. 
in circumference, the left 2:\. 7 c. There is absolute loss of electro-mus- 
cular Contractility in all the muscles of left leg. The left leg is \<r\ cold, 

ami its circulation feeble. I frequently called the attention of the resident 




Antero-spinal Paralysis 
• 1 1 in.) 



1 De 1' Electrisation localis6e, Paris, 1872, p. 487 et seq, 

■ Papers of Petitfils. 

:t Arehiv. de Physiol. Norm, et Path., 1878, pp. 80-87. 

« De la myelite aigUe, Paris, 1872. 

B Consideration Bur I' atrophic "aigUe des cellules mortrices, Paris, 

'■ Anli. for Psych, nml NVn t-nk rank ., 187 1. 

7 Diseases of Nervous System, N. fork, 1877, p. 470 ol seq. 

h Spinal Paralysis, N. York, 1874, and Anterior Myelitis, 1877. 



is 



ANTERO-SPINAL PARALYSIS OF ADULTS. 249 

staff and of friends to this remarkable case as one of the same kind as that 
which, occurring in the early years of life, we call infantile spinal palsy. 
The subsequenl history need not be reported. No treatment did any 

good; the girl remained in the hospital without any active symptom, and 
went away October 3, 1873, carrying this wasted lefl leg. She was em- 
ployed as a help in the wards of the Convalescent Hospital on Hart's Island, 
and was there much exposed to cold. 

The second attack, of which patient gives a good account, came on late 
in December, 1873. Had pains "like rheumatism" in right leg; there 
was a feeling of pins and needles in the limb, this numbnQSS extending 
above the knee. Six' is positive that on the fourth day the right leg was 
completely paralyzed. No symptoms in left leg. No bedsore, and no 
affection of bladder or rectum. Re-admitted to the Epileptic and Para- 
lytic Hospital, March 3, 1874, with atrophy and palsy of both legs ; no 
acute symptoms. 

During the spring and summer this patient rather gradually lost strength 
in the thighs, in the right most. She also exhibited a variety of interest- 
ing visceral disturbances, consisting of amenorrhea, lasting two and three 

D DO 

months ; the menses then appearing with much pain, the blood abundant 
and in clots; there were also pains in the back and lower abdomen. On 
many days in this period the urine had to be drawn off with the catheter, 
and it often was bloody, exhibiting a heavy mucous deposit, and contain- 
ing albumen. The microscope showed only leucocytes and a variety of 
epithelial cells — there being probably both pyelitis and cystitis. Since 
the middle of September has not required the catheter, and, with excep- 
tion of palsy, has been better. 

Re-examined October 25, 1874. Patient, when she first came in this 
year, walked ill with a crutch and stick; is now able to walk with two 
sticks (result of education). Cannot stand or walk without help. The 
patient is a stout and healthy girl, exhibiting nothing abnormal above the 
hips. Both lower extremities are extensively palsied and much wasted. 
The left leg (first attacked in 1871) shows no voluntary movement below 
the knee, with exception of slight separation of the toes. As the patient 
lies on the bed she is able to raise the extended limb as a whole ; but 
the strength at knee-joint is small. The thigh is thin and flabby ; the leg 
is the seal of extreme atrophy, and looks just like the same part in c 
of infantile spinal palsy, there being apparently only connective tissue and 
fat around the bones, the skin being bluish and very cold to the touch. 
The right lower extremity (paralyzed in bs7o) is in a very similar though 
less extreme state. All voluntary movements are possible with tin- foot, 
though they are feebly performed. The limb, as a whole, cannot be raised 
from the bed, and flexion at knee-joint is weak. The quadriceps exten- 
sor femoris is wholly paralyzed ; the flexors of the thigh upon the body act 

feebly; the adductors fairly. Both feel lie extended and adducted ; toes 
flexed. The right leg is, like the left, extremely wasted, bluish, and (piite 
cold. Sensibility to contact, pain, and temperature are preserved in both 
limbs. Tickling is felt, but produces no reflex movement in the palsied 

parts. The electro-muscular reaction of the atrophied muscles of both 
limbs is lost (both currents). At present, urine i> passed normally. The 
patient's arms, shoulders, and chest are large and rounded, standing in 

remarkable contrast to the dwindled legs. There have been no bedsores 
and no spinal epilepsy. 



250 DISEASES OF THE SPINAL CORD. 

Circumference of right thigh (lower third) . . .31.5 c. 
Left " " " ... 30.5 

" right calf 24.0 

left " 21.5 

" forearms . . . . . .25.0 

On a healthy girl (non-palsied) of same proportions as the patient the 
following measurements are obtained: — 

Circumference of right calf ...... 35.0 c. 

left " 34.5 

" forearms . . . . . .24.0 

The patient having been in bed some time, well covered up, lias a ther- 
mometer held between the great ami second toes of each foot for three 
minutes, with results: Bight side, 84.25° Fahr. ; left side. 86 c Fahr. 

In March, 187G, the patient came under my charge, when I found that 
her condition was somewhat aggravated. She manages to go about with 
tli'' aid of crutches, but has utter loss of power below the knees. The tac- 
tile sensibility is much lowered, and tickling can be borne without any 
reflex movement being produced, and she has lost control to a great ex- 
tent over the bladder and rectum. 

Another case reported by Lincoln is well worth presenting as illus- 
trative of this form of disease beginning without fever. 

A tall, stout man, 1 40 years of age and of previous good health, noticed 
one morning, without any previous symptoms, a feeling in his legs as if 
fchey had fallen asleep. The feeling came on again and again through the 
day. and he began to be a little weak in the legs. In the afternoon, when 
trying to step upon the platform of a street car, he failed, and had to be 
helped in. On arriving home, he was able (with assistance) to walk up 
>t,-iir> to his bedroom, and went to bed, where ho remained. 

When seen by Dr. L., two days later, lie felt well, no giddiness, muscles 
of face and eyeballs under perfect cdntrol, pupils normal in size and con- 
tracted well, speech natural, vision and hearing without defect. The 
bladder and rectum performed their functions normally. The senses of 
touch, pain, and temperature were normal in the hands, and nearly so in 
the feet. Reflex contractions could scarcely lie obtained from the soles. 

There were no abnormal sensations. Pulse, <si>; temperature, 98 \ No 
albumen in the urine. 

The muscles of the neck and limbs, except below the knees, were gene- 
rally in a condition of semi-paralysis, lie lay on his back almost help- 
less ; could not raise his head from the pillow without some help, and 
Could not raise hi- knees from the bed by Hexing the thighs. The grasp 

of his hand was \ r erj feeble indeed. There was no paralysis of any mus- 
cle. Below the knees lie seemed to have more strength. The weakness 
was much more marked on the left than on the right. 

Treatment consisted ai first in mix vomica and cinchona, and subse- 
quently tincture of iron with strychnia, ami Horsford's acid phosphates of 

line- and magnesia. On tire fifth day of the attack, treatment by the 
induced electric Current «018 begun, when it was found that some at least 

of the muscles had l"-t pan of their susceptibility to this stimulus. The 
1 Boston Medical and Surgical Journal, March 25, 1 s 7 G . 



ANTERO-SPINAL PARALYSIS OF ADULTS. 251 

loss went on increasing until the twenty-first day, when the galvanic cur- 
rent was substituted, a descending current being applied to the spine, and 
interrupted currents to the muscles, three times a week ; tie- faradic cur- 
rent was also continued for a few weeks. 

The hot-air bath to profuse perspiration was used just before the appli- 
cation of the currents, together with regulated gymnastic exercises. The 
paralysis of the muscles was gradually relieved under this treatment to a 
very considerable degree. The patient's improvement was very gradual, 
and it was six months before he was able to ride out. He finally was en- 
abled to attend to his business pretty much as before the attack. 

Other cases begin much more slowly, and several of this kind are re- 
ported by Duchenne, but the origin of the disease is nearly always sudden. 
There may be pain and dysaesthetic symptoms, or no warning at all. the 
patient awaking in the morning and finding himself paralyzed, as was tie- 
case with Seguin's patient. Like the infantile form, there may be an 
acute attack of fever, which may last for several days, during which there 
is usually delirium or rigors. The paralysis appears during this time, and 
may be general, so that the upper and lower limbs are affected ami the 
loss of power is complete. The functions of the bladder and sphincter ani 
are always normally performed until other parts of the cord are affected, 
and there is neither incontinence of urine nor involuntary evacuations. 
At the end of a few weeks there is a commencing improvement, some of 
the muscles regaining their lost power and contracting quickly under 
electric stimulus, while atrophy of those already paralyzed begin- to take 
place. The skin over the paralyzed limbs is quite cold and blue, and 
there is diminution of temperature and faradic excitability, while ulti- 
mately it is impossible to provoke any response, and the limbs become 
deformed and twisted. Atrophy of deeper parts follows, and the bones 
become reduced in size, while the articular ends appear large in contrast 
with the attenuated size of their shafts. Sensibility is rarely disordered, 
though exceptional cases of anaesthesia or hyperesthesia are met with, but 
nf'ter the inflammation has involved the posterior columns the phenomena 
of general myelitis are presented. Dysesthesia? are common, and the 
patients complain of subjective cold, various pains, and the waist-constrict- 
ing band. The muscles of the face, neck, chest, and abdomen are rarely 
affected, but the extremities remain deprived of pain after there has been 
a considerable retrocession of the original complete paralysis. The atro- 
phy is rapid, and differs from that of progressive muscular atrophy in the 
fact that whole groups are affected at a time, while the peculiarity of pro- 
gressive muscular atrophy is that muscles are irregularly affected. Then- 
are ne\ er bedsores. 

Erb 1 alludes to a light variety of spinal paralysis, which has been de- 
scribed by Kennedy, Fry, and others. To this variety has been given 
the name " temporary spinal paralysis." The paralysis is characterized 
h\ its brief duration, and may involve a limited group of muscles <>!• seve- 
ral groups. It would seem, therefore, thai there .-ire two varieties: the 

1 Archiv fur Psychiatric, Hand \., Heft 3. 



252 DISEASES OF THE SPINAL CORD. 

temporary and permanent ; but Seguin and others have made the classifi- 
cation acute, subacute, and chronic^ which is based rather upon the 
variety of myelitis than the paralysis. Duchenne applies the term sub- 
acute to the former, which begins without fever, attacks the lower ex- 
tremities first, and, extending upwards, involves the muscles of respiration 
and deglutition. 

Causes. — The same unsatisfactory history of exposure, fatigue, and 
peripheral irritation is connected with the history of this as well as other 
spinal diseases. In four of Seguin's cases surface exposure to cold is said 
to have produced the attack, and in three other cases " refrigeration" is 
named, while in others dysentery, measles, and other acute diseases were 
at the origin of the trouble. 

As regards age and sex, I can do no better than refer to the tables of 
Seguin. All of the patients whose histories he collected were of middle 
age. "The greatest age at the time of seizure was 62 years, the least 18 
years." Among 17 cases reported by various observers, there were 13 
nun and 1 women. 

Morbid Anatomy and Pathology. — But very little light has 
been thrown upon the morbid anatomy of the cord, which accounts for 
this form of paralysis. Chalret 1 and Gombault 2 have reported two cases. 
The appearances found may be briefly enumerated as these: The horizon- 
tal fibres which pass from the anterior horns to form the anterior spinal 
nerve-roots were diminished in size, and the large ganglion-cells of the 
anterior roots were atrophied, having undergone yellow pigmentation. 
Some of the nerve-cells which had not undergone this form of degeneration 
were also reduced in size. This information is very meagre, though these 
two cases illustrate the pathological anatomy of the disease. Charcot and 
the majority of observers believe that the situation of the lesion is always 
in the anterior horns. The only matter of dispute seems to be whether or 
not there is primary degeneration of the cells, or an acute interstitial mye- 
litis and secondary injury of the nerve-cells. This latter view is held by 
Erb, 8 and, I think, is being generally adopted. 

The muscles were found to be in a state of fatty granulation, which is 
the case in the infantile variety. In some respects the disease resembles 
progressive muscular atrophy and bulbar paralysis, the lesion being atrophy 
of the motor and trophic cells, but it is probable that the trophic cells are 
primarily affected in these latter diseases. 

Diagnosis. — Antero-spinal paralysis is likely to be sometimes mis- 
taken fbr progressive muscular atrophy. It' we bear in mind its sudden 
Or almost sudden and complete origin ; the absence as a rule of fibrillary 
tremors (only two cases which presented these symptoms having been re- 
ported); thai the paralysis precedes the atrophy, and retrocedes after the 
firs! general attack; thai elecXric irritability is primarily lost; and thai the 
atrophy involves the muscles of one or more (usuallj two) limbs, there 



1 Thfese de Paria, 1872. 

1 Archiv, de Physiol., Norm, el Path., tome \. 1878, 3 Op. oit. 



ANTERO-SPINAL PARALYSIS OF ADULTS. 253 

need be no error made in diagnosis. Anaesthesia, incontinence, and pa- 
ralysis of the sphincter ani prevent it from being confounded with general 
myelitis, these symptoms belonging to the latter in addition to the 1"-- of 
power and atrophy. Spinal congestion may sometimes give rise to some 
of t he symptoms, and Cartwig 1 presented a ca9e which he called "inter- 
mittent," somewhat resembling the lighter form of true antero-spinal 
paralysis. 

A sugar-baker, aged 23, who was exposed to great heat and sudden 
changes of temperature while very lightly clothed, had suffered in his 
eighteenth year for four or five weeks from an attack of tertian ague, from 

which he recovered. One day he perceived a Dumbness in his leg-, which 
rapidly attacked his arms also, ami finally led to complete paralysis of tic- 
muscles of the neck. Speech, deglutition, and respiration were somewhat 
impeded; the muscles of the eye were unaffected, as were also the alvine 
and urinary excretions, and sensation. After twenty-four hours there was 
a remission of the symptoms; first the neck began to become movable, 
then the fingers, arms, body, and finally the legs. All this took place in 
half an hour, and was followed by an increase of perspiration. During 
the next twenty-four hours the patient remained free from paralysis, but 
was dull; after which, the above-described symptoms returned. The 
brain was always free; the cervical portion, especially the upper, was not 
always equally affected; the movements of the neck were often free; and 
difficulty in deglutition and respiration, inequality of the pupils, and myo- 
sis, were frequently present. The phrenic nerve was always unaffected. 
When there was not complete paralysis, the affected limbs were generally 
stiff, and there was contraction of the predominating groups of muscles; 
when complete paralysis was present, the muscles were soft and flabby. 
Electro-muscular irritability was almost completely absent during the pa- 
ralysis, and the violence of the muscles varied. Under the use of quinine, 
the patient's condition was on several occasions quickly improved, but he 
was not cured. He was under observation for more than six months. 
The author believes that the case was one of masked intermittent, and 
that the phenomena were due to hyperemia of the cord and occasional 
increase of serous exudation. 

In spinal congestion there are no deformities, no atrophy, and nearly 
always vesical trouble and constipation. 

Acvte ascending p aval \//s is has been described by the French writers, 
and resembles very closely certain forms of the disease under consideration. 
In one remarkable case of this kind reported by Desjerine, 8 no morbid ap- 
pearances were found after death. A man (altered the hospital suffering 
from undefined pain in the lower limbs, and two days after became para- 
plegic without any loss of sensibility. The paralysis rapidly ascended, 
and. alba- four days, he died; no trace of disease after paralysis of the 
respiratory muscles could be found except dilated ve--.rU. 

Seguin considers that this involvement of the respiratory muscles is a 
diagnostic sign. 

1 Centralblatt f. d. Med. Wiss., dime 15, 18 

2 Archives de Physiol., etc.. June, i^7<;. 



254 DISEASES OF THE SPINAL CORD. 

Prognosis — Antero-spinal paralysis is not a disease which is rapidly 
fatal, and many cases recover within a short time after the beginning of 
the attack. I am not disposed to think that the lesion is an ascending 
one; but rather that, if it progresses at all, it involves the posterior parts 
of the cord in the majority of cases, and does not spread longitudinally. 
This is probably the condition of affairs in the ease of S. W. Should the 
paralyzed muscles become atrophied to such an extent that deformities 
result, I think that there is very little hope for the patient. If, however, 
the muscles can be made to respond to the galvanic current, we should 
never be discouraged. 

Of the cases reported by Duchenne, Meyer, Hammond, Bernhardt, Se- 
guin, and others, I find that of 1G cases there were but 2 deaths. In one 
case there was improvement in six months, in another in four, and in 
others two, three, eleven, and twelve. In two cases the patients were 
cured, and in several there was progressive unfavorable advancement. 

Treatment In electricity we possess a remedy of the greatest value. 

I have already called attention to its use in the infantile form of the dis- 
ease, so there is no need for going into details. It is well to use both the 
galvanic and faradic currents, and in the acute form of the trouble wo 
should begin with counter-irritation of the spine as early as possible, and 
for this purpose may employ blisters or the actual cautery. 

Ergot and belladonna in rather full doses should be employed in con- 
junction therewith (F. 7G). Seguin recommends leeching and dry cups, 
w hieh are both excellent. 

Should the pain be severe, we may use morphine by means of the hypo- 
dermic syringe; or spinal galvanization. The after-treat ment should be 
with the galvanic current. Hammond has benefited some of his patients 
by the use of the iodide of potassium and ergot, but it is probable that 
ergol possesses the most value. 



PROGRESSIVE MUSCULAR ATROPHY. 255 



CHAPTEE X. 

DISEASES OF THE SPINAL CORD (Continued). 

PROGRESSIVE MUSCULAR ATROPHY. 

Synonyms — Wasting palsy; Cruveilhier's paralysis; Progressive 
muskelatrophie ; Progressive muskelTahmung. 

Definition This is an essentially progressive atrophy of certain 

groups of muscles. It is not preceded by any paralysis, but followed by 
loss of power, and terminates usually by involvement of the respiratory 
nerve-centres. 

Cooke, 1 in 179"), directed attention to a condition he called l( anomalous 
hemiplegia" which was clearly progressive muscular atrophy, and bis 
was probably, the first recorded case. Bell, 2 Abercrombie, 3 and Harwell 4 
each published cases which were undoubtedly of this kind; and. in 1836, 
Mayo"' related two cases. It was not, however, till 1849, when Duchenne 
de Boulogne 6 presented a memoir to the Institute of France, entitled 
" Atropine musculaire avec transformation graisseuse," that the pre- 
sent disease was recognized. In 1853, Cruveilhier 7 described some c 
in which the atrophy was general, all the voluntary muscles being affected. 
In 1850-1856, Aran, 8 Duchenne, 9 and Eisenmann 10 brought forward 
additional facts, and the latter agreed with Cruveilhier that the "nerves 
or nervous centres are at fault anterior to the muscles, and that the 
atrophy of the latter is a secondary process." Since that time we are in- 
debted to Roberts 11 for the most clear and instructive article that has vet 
been written. 

Symptoms — The appearance and progress of the disease are most 
gradual. The affected individual may first notice a slight weakness in 
• •nc of the upper extremities, and it hi' be a tailor, as was one of niv pa- 
tients, he finds difficulty in handling his shears. Perhaps the firel indica- 
tion of trouble which suggests to the patient the commencement of the 

1 Cooke on Palsy, p. .SI. 1822. 

2 The NervOUS System of the Human Body, London, i 

3 On the Brain and Spinal Cord, p. II 9, IMin.. lj 

4 Lend. Med. ( In/.. \ ol. \ ii. p. 203 . 

6 Outlines of Unman Pathology, p. 117, London, 1886. 

6 Memoires de I'Acad. ties Sciences, 1849. 

' Archives den. de Med., May, I- 

8 Ibid., Sept. I860. 

9 De 1' Electrisation localise, Paris, 1850. 

10 Canstatt's Jahresbericht, I - 

11 An Essai <ui Wasting Palsy, London, 1868. 



256 



DISEASES OF THE SPINAL CORD. 



disease, is when the act of writing is attempted. According to Roberts, 
the disease begins, in two-thirds of the cases, in the upper extremities, 
and the muscles of the hands arc the first to suffer loss of function. Very 
often several muscles are affected together, and they soon become agitated 
by what are known as fibrillary contractions, or, as they have been called, 
vermicular contractions. The subcutaneous contraction of muscular fila- 
ment- suggests the appearance of worms crawling beneath the skin, and 
there is sometimes a species of muscular shivering. These fibrillary 
contractions may be excited by sharply striking the muscles with a ruler 
or the hand, and they sometimes follow the passage of the galvanic cur- 
rent through the nerve-trunk. As I have said, the hand may be affected 
first, and there may be extensive wasting here before other parts are 
attacked. The muscles of the palm of the hands, when atrophied, give to 
that member a most unsightly appearance. The bones stand out in strong 
relief, and the thenar and hypothenar eminences are flattened, and the 
flexor tendons are prominent, and increase the deformity. With this 
there is contraction of the flexors, and the hand resembles more the claw 



Fin. 36. 




Main en Griffe." (Roberts.) 



(Fig. .°>P>) of an animal than anything else, so that it has been called "le 
main en grille." The back of the hand also presents a most skeleton-like 
aspect, the extensors, the interossei muscles, and sometimes the adduetive 
of the thumb having been reduced in size. The forearm and arm are 
next to follow, and rapidly lose their normal conformation. The deltoid 
and serrati muscles may be involved, while those of the arm proper may 
occasionally be passed over. The head of the humerus and angle of the 
scapula are quite distinct, and this bone maybe drawn out of place by the 

healthy muscles, this being the rule when the serratus magnus is the seat 
of atrophy. The angle of the scapula is drawn upwards and inwards, ami 
Stands OUl from the hunk. It i- rare to lind symmetrical atrophy, and in 

th<- majority of cases I have seen there lias been a great difference in the 

invasion of mU8Cle8 on the two sides. The right upper extremity appears 

to hr the favorite Beal of the atrophy, while the lower extremities are 
quite rarel) affected, and in [he proportion of 1 to 12 to the upper ex- 
tremities. The muscles oj* the face and head are sometimes the seat of 
atrophy, but this is unusual, though muscles may occasionally be so ex- 
tremely wasted that there is no appearance of intelligence whatever. The 

eyes, of course, being unaffected are the only agents of expression. There 



PROGRESSIVE MUSCULAR ATROPHY. L ; .jT 

may be atrophy of the tongue and buccal muscles, with disturbances of 

speech and drooling of saliva, and in such cases death usually follow- 
in a very short time. Sometimes the muscles of the neck do not escape 
the extension of the disease, and the chin falls forwards and downward-. 
The last muscles involved are generally those concerned in respiration; 
and not only are the intercostals the subjects of such a change, hut the 
diaphragm is finally paralyzed, so that the action of the lung- is interfered 
with, and ultimately the patient is literally asphyxiated. Subsequent to 
atrophy, a loss of power takes place. The affected muscles preserve for a 
long time their electro-contractility ; but this is finally lost as they decrease 
in size, and loss of power increases till finally the patient becomes helpless. 
Tactile sensibility is, however, rarely blunted. One of the earliest symp- 
toms of progressive muscular atrophy is the presence; of dull pains in the 
affected limbs, and this has led very frequently to a mistake in diagnosis, 
the condition being often considered rheumatic. In one case sent to me 
by Dr. E. G. Loring, I found that the atrophied muscles were the deltoid, 
serratus magnus, and biceps, but none of the lower muscles of the forearm 
were attacked. The man had consulted another physician, who considered 
the case one of chronic rheumatism, and prescribed liniments and alkalies. 
The patient was an upholsterer, and had been obliged to use his right arm 
to a great extent, especially in hammering on cornices, and putting up 
decorations which were above his head. He had had violent pain in the 
shoulder for some months, and subsequently the atrophy began in the del- 
toids. When I saw him the head of the humerus was prominent, and 
there were fibrillary contractions in some of the muscles of the back. The 
progress of the disease is marked by the occurrence of well-marked inter- 
missions, and a year or two may often pass without any extension, while 
at the end of that time a fresh start is taken, and two or more of these sta- 
tionary periods are not uncommon in the course of the malady. The 
ordinary tendency of the affection is however progressive ; and although, 
as I have said, the disease may pursue the most eccentric course, attack- 
ing groups of muscles here and there, it will involve ultimately a very 
great number, and finally those supplied by the lower cranial nerves, unless 
it be checked by proper treatment. 

I may illustrate the symptomatology of progressive muscular atrophy by 
a case which ran a somewhat irregular course by attacking the muscles of 
the lower extremities : — 

J. F. II., 31 years old; 1'. S. ; engineer. Twenty-one months ago the 
patient, after exposure, developed what he say- wa- articular rhemnat i>m. 
which chiefly affected the legs. On recovery he noticed that the right leg 
u began to grow smaller at the calf," and thai afterwards his left thigh 
became smaller. His pains continued at inters al.-. and were increased by 
damp weather. 

Present Condition The muscles of the anterior pari of legs and thighs 

are much wasted, the adductors of thighs and the recti femoris on both 
sides being notably so. The knees Beem verj large, and the condyles of 
the femur are felt to be superficial and covered tightly 1>\ the -kin. There 

17 



258 



DISEASES OF THE SPINAL CORD. 



is do loss of sensation, and electric irritability appears to be very generally 
preserved, except in the recti femoris. The glutei muscles have suffered 
to some extent on both sides. He has severe pain at night, which runs 
down the legs, and " seems to be deep." There is impaired motor power, 
and he rinds that walking is difficult. He does not experience any urinary 
trouble, and his bowels are not constipated. There is no loss of coordi- 
nating ] lower, no constricting band, no history of any kind of acute mye- 
litis. The muscles on the outer side of the thigh are the seat of fibrillary 
contractions, which occur sometimes when he makes a voluntary effort. 
There was at this time no atrophy of any of the muscles of the upper 
extremities, but when I saw him some months subsequently there was 
commencing atrophy of the muscles of the right hand. In the paralyzed 

Fie. 37. 




Atrophy of Left Shoulder. 

muscles the temperature is much lowered, and this is a constant feature ot 

the disease. Jaceoud 1 and others have called attention to a temperature 
change, which they call " refroidissemenl variable," in which there are 
iiuic> when the temperature may fall several degrees, and this seems to be 
the result of a paroxysmal ischaemia of the tissues. The papillary condition 
i- an interesting feature of the disease, the dilators sometimes being para- 
lyzed, bo that the pupils are widely or unequally dilated. 

Causes These may be enumerated as heredity, which is found to 

enter conspicuously into the etiology of progressive muscular atrophy, 
exposure, the over-use of particular <jr<>ui>s of muscles, injur;/ of (he sj>/- 
ikiI cord, and sometimes typhilis and the ymotic diseases. As to the 
hereditary influence which favors ii- development Friedrich* reports several 



1 On. 



:;■_'<;. 



■ Ueber Muskelatrophie, etc Berlin, 1878. 



PROGRESSIVE MUSCULAR ATROPHY. 25Q 

cases, and Hammond 1 others, which go to show that this disease more than 
all others commonly appears in several generations of the same family. 1 
have seen one case; where it could be traced for three generations hack, 
and in another, which I will presently detail, there were uncles and aunts 
affected. Eichert, 2 in a very valuable article, gives the family history of 
one case. In a genealogical table he traced the disease hack six genera- 
tions, and representatives of these generations arc still living. Seven 
cases are related by him. In two of the cases the parents have escaped, 
while the children have suffered. It is unnecessary to pursue this matter 
further, but I am firmly convinced that there is no other disease, except 
perhaps it may be phthisis puhnonalis, which is transmitted so frequently 
as this terrible malady. Exposure to damp, neglect to change wet cloth- 
ing, and like imprudences, are exciting causes in many cases. Neuralgic 
pains are very prominent in such cases, and the onset of the disease is 
rather precipitate. Mechanics of all kinds, who are in the habit of* using 
some muscles much more than others, are frequently the victims of the 
disease, and the muscles which have been over-used are affected before the 
others. The case of a ballet-dancer is reported by Hammond in which 
the sural muscles were affected, and I have seen the same limited atrophy 
in a cigar-maker and in a compositor, who used certain groups of muscles 
almost constantly. Roberts has dwelt upon the connection between injury 
of the spinal cord and the disease under consideration; and Valentiner. 3 
Bergmann, 4 and Tliudicum have, all called attention to the appearance of 
the disease some time after the receipt of an injury. Roberts reports a 
case in which atrophy of the ball of the right thumb, and subsequent com- 
plication of the respiratory muscles, and death followed a slight injury 
received six months before. The other cases are none the less interesting, 
and go to prove the importance of recognizing such causes. As to age and 
sex it has been found that progressive muscular atrophy is not confined to 
any period of life, but the bulk of cases occur after puberty. Of 88 cases 
reported by Roberts, 1 was only "2 years old and another 69. Of the 
28 cases I have seen, the atrophy began in 2 between the 5th and 10th 
years; in 5 between the 10th and 15th ; in IS between the 20th and the 
30th; and in 3 after the 30th. Of these, 23 were men. and but 5 
women. This seems to be the rule, and Roberts states that mx men are 
affected to every woman, and he considers this due to the exposure and 
external violence to which males are subjected. 

Morbid Anatomy and Pathology The disputed point in regard 

to the pathology seems to he whether it is a primary peripheral Condition, 
of whether it is a central affection in which the trophic cells are affected. 
The advocates of the tirst theory call attention to the tact that muscular 
atrophy occurs independent of any loss of the muscular function, and 

believe it to be purely a local degeneration. The authorities 1 hai e Bpoken 

1 Op. cit., |>. 526. 2 Berliner Klin. Wochenschrift, Oct. •-'". Lfi 

2 Prag. Viert., 1855. ' Petersburg Med. Zeitsch., L864. 



260 DISEASES OF THE SPINAL CORD. 

of, in alluding to the early history of the disease, all believed in this intra- 
muscular origin, but lately there have been so many proofs of its central 
origin brought forward, that the former theory has been abandoned. This 
difference of opinion seems to exist in regard to the form of central lesion. 
The majority of observers are agreed that there is an affection of the 
anterior horns; and that the change is one that affects the trophic cells 
of Duchenne and WestphaU, and the fibres which connect with sym- 
pathetic ganglia. 

To Lockhart Clarke, 1 who has so often decided questions regarding the 
pathology of nervous disease, belongs the credit of having discovered the 
central origin of this disease. He has found atrophy of the anterior gray 
horns, and since his original observations many other observers have 
come forward to endorse his views. Von Recklinghausen and Dumenil 3 
disagree, however, with this view, and the microscopical examination 
made by the former Mas unattended with any discovery of morbid ap- 
pearances. 

Jaccoud has collected six cases in which fatty degeneration of the sym- 
pathetic had taken place, and one of them was observed by Jaccoud 
himself. Not only was there fibro-fatty degeneration of the sympathetic 
nerve, but there was atrophy of the anterior roots. The view held 
by Jaccoud is that the trophic filaments of the sympathetic which pre- 
side over nutrition do not perform their duty, and that the affection of 
a mixed nerve, which contains motor, sensor, and trophic filaments, at a 
point where they are intimately mixed, must result in a perversion of all 
their functions, but if the separate filaments be attacked at a point before 
they become blended, there may be independent loss of function of either 
one. 3 

Charcot 4 and Gombault have described the following interesting post- 
mortem appearances witnessed in a recent case : — 

" No change in hemisphere, cerebellum, pons, or medulla oblongata in 
these nerves. The gray substance of the cervical and dorsal medulla 
spinalis was greatly altered from the lower portion of the cervical enlarge- 
ment down, gradually decreasing downwards and outwards. The nerve- 
cells and nerve-fibres of the anterior gray cornua had disappeared; the 
Capillary vessels were greatly developed; the parietes of the smaller and 



1 Brit, and For. Med.-Chir. Review, vol. xxx., 18G2. 

2 Gaz. Hebdom., 1867. 

1 The localization of well-defined lesions in this disease is sometimes made be- 
fore death and verified afterwards. Prevosl and Cotard (Archives de Physiol., 
Sept. L874) presenl such a case. There was atrophy of the right thenar eminence, 

with afrOphj ul' the light anterior root of the eighth pair of cervical nerves, slightly 
marked atrophy of the right anterior root of the seventh cervical nerves, and 
atroph) of the gra\ matter of t Itc anterior horn at this level of ahont an inch in 

extent. * 

1 Archiv. de Physiol., i*7.~>. No. •">. abst. Phil. Med. Times. 



PROGRESSIVE MUSCULAR ATROPHY. 201 

larger vessels were thickened. The lumbar portion of the cord and 1 1 1 < - 

lateral columns were normal. In the cervical and dorsal region, the por- 
tions of the cord near the merging external roots were sclerosed ; the 
change being proportionate to the intensity of that which had taken place 
in the gray cornna. The few ganglion-cells present were very much 
diminished in size, without processes, more rich in pigment than normal, 
but still containing nuclei and nucleoli. The anterior roots of the 
cervical region were atrophic; empty sheaths, frequently containing large 
nuclei, appeared in place of the normal fibrillar contents. The posterior 
roots seemed normal. 

"As to the peripheral nerves, one phrenic and several intercostal nerves 
were examined ; more than two-thirds of the nerve-tubules (in hardened 
sections) were wanting, by a process similar, as it would appeal-, to that 
induced by an external wound. The muscles about the shoulder and the 
upper extremities were for the most part atrophic; there seemed to be a 
peculiar atrophy of the primitive fasciculi, without any marked alteration 
in the fibrils, and without any excessive development of the interlibrillar 
fatty tissue." 

Lockhart Clarke 1 has discovered marked changes in the gray matter. 
There was a granular deposit about the vessels, and corpora amylacea 
about the central canal. Lesions of the anterior nerve-roots were found, 
and in the cervical region there seemed to be more distinct appearances 
than at any other point, where it will be remembered there may be found 
sympathetic as well as motor and sensor fibres. 

The muscles present distinct evidences of fatty degeneration and fatty 
substitution. They appear to the naked eye as wasted bands which con- 
tain lines of fat. The appearance of healthy muscles of good contour in 
juxtaposition with others which have undergone atrophy is very peculiar, 
and it is difficult to realize that the disease can involve such isolated 
tracts. The muscles of the lower extremities may have undergone general 
fatty degeneration. A specimen prepared by my friend Dr. Weiss, of the 
Medical Department of the X. Y. University, shows very beautifully this 
condition of affairs. Fatty substitution has gone on to such an extent 
that there is no appearance of muscular fibre to be seen, but every muscle 
exists as a distinct band of adipose tissue. Atrophied muscles have been 
examined by Meryon, 2 Galliet, 3 and others, and their descriptions of ap- 
pearances agree very closely. The muscular structure Buffers a complete 
change, the striae disappearing and the sarcolemma undergoing a granular 
change. Fox 4 divides the secondary changes into the fatty degeneration 
which takes place inside of the sarcolemma, and as an interstitial deposit. 
These he calls the parenchymatous and the interstitial. Sometimes, as 
observed by Robin, the atrophy may take place as a fibrous degeneration, 
or species of muscular sclerosis. Some muscles appear as fibrous i-^viU of 
a white color, while others may be found which have undergone the tatty 
degeneration just described. 

1 Med. Chir. Trans., L851, 1856. ■ Ibid., I - 

8 Archiv. Gen., vol. i., 5meserie, 1858, p. 584, i Op.cit., p. 266, etseq 



269 DISEASES OF THE SPINAL CORD. 

An instructive case in which very striking appearances were presented 
was observed by my friend, Dr. J anew ay, whose observations are recorded 

below : — 

M. G., aged 62 years, widow; admitted to hospital December 16th, 
1873. Right hand: the muscles of ball of thumb are very much atro- 
phied, and she is unable to move it; there is also slight rigidity of the 
joints of the thumb. 

Dorsal interossei are very much wasted; there is slight power of flexion 
and extension of lingers, especially little fingers, and there is also a slight 
movement at tin 4 wrist. 

Sensibility good, except in index finger, and here it is decidedly dimin- 
ished. She can raise her arm to her head and pla.ee it in any position. 
Hands seem eold. 

Left hand is not so much affected; the muscles of ball of thumb are 
partially wasted. The abductor opponens and outer head of flexor brevis 
are almost gone ; the inner head of flexor brevis and abductor partially, 
and capable of acting to a slight extent. Has slight power of ab- and ad- 
duction of lingers, especially the little finger, most on the ulnar side, and 
decreasing toward the radial ; has slight power of extension over fingers, 
none over thumb, but flexion power is more marked. Has no power of 
extension, but considerable of flexion at the wrist. 

Dynamometer L. II. 2$. Sensibility normal ; hands cold. The mus 
cles that are capable of acting respond to the induced current very well. 

July !>. Complains of dizziness and nausea. 

Ylth. Dizziness still. Her hands are in same condition. She expe- 
riences some difficulty in walking, and moves with her body " sloping 
over." She cannot use her hands, and when she attempts to do any- 
thing, they drop, and she cannot raise them. The muscles that remain 
unaffected respond well to electricity. She still vomits at times after 
eating. 

August 3. Is quite weak ; has chilly sensations. 

\th. Had a severe lexer last night; temp. 104°; passed feces in bed, 
and did not know it ; to-day temp, is almost normal ; is quite apathetic. 

5tk. Has chilly sensations ; complains of no pain ; arms and jaws trem- 
ble ; ten. p. 102°. 

2 P. M. Temp. !<>-_> . 

(\t//. She is mtv much worse ; mucous rales heard all over chest ; respi- 
re lion accelerated ; temp, high ; pulse very feeble ; pupils normal ; bowels 

moved once to-day ; swallows with great difficulty. 
2 V. M. She sank gradually, and died at 12. [5 P. M. 

Post-mortem, held twenty-seven hours after death Rigor mortis mode- 
rately well marked. Nearly all the muscles of the hands are atrophied, 
especially the dorsal interossei and the propria, muscles of the thumb; the 
change is nearly symmetrical in both hands. The forearms are extremely 
wasted, both on the flexor and extensor surfaces. There is no marked 
wasting in the arms, the shoulders are well rounded; both pectoral regions 
appear wasted ; there i> no marked wasting in the lower extremities, un- 
less ii be in the adductor region of both thighs. Incisions made into the 

pectoral muscles Bhow vgpll-colored fibres also in the deltoid, biceps, and 
triceps. 

Tin- extensors of the forearms are of whitish-yellow color, being nearly 
n- bale a- lh«' >kin. 



PROGRESSIVE MUSCULAR ATROPHY. 203 

The flexors of right hand are very much wasted, but not so much as 
the extensors. The flexors of the left side are Bmall, but seem in good 
condition. 

The muscles of the right thenar eminence show extreme degeneration. 
In left thenar eminence the inner head of flexor brevis and adductor arc 
red and large ; the external is white, as on the other Bide. The adductors 
of thighs are small, but well-colored. 

The quadriceps extensor femoris is of good color. 

The anterior tibial muscles are of good color. 

Heart: Valves are normal, muscular substance soft and yellowish-gray. 
The diaphragm is not atrophied. 

Brain : Convolutions and corpora striata appear normal. There is some 
atheroma of the carotid and basilar arteries. 

The substance of the cord and brain is quite soft. The viscera are 
normal, except the kidneys, and these are granular; their pyramids are 
small, and they contain small cysts. 

Diagnosis. — Progressive muscular atrophy may be mistaken for seve- 
ral conditions of a paralytic nature, among these lead paralysis, antero- 
lateral sclerosis, and partial paralysis from traumatism. 

For an illustration of the first of these I do not think I can do better 
than mention a case in which there appeared to be lead paralysis, hut 
which subsequently turned out to be progressive muscular atrophy. 

Several months ago Mr. N., a Cuban gentleman, came to me with a 
letter from his medical adviser, Dr. Findlay, of Havana. The doctor's 
history of the patient is as follows: " Mr. N., about eighteen months ago. 
began to experience a tremor in the fingers and wrist of the right hand, 
together with muscular debility, which caused some inconvenience in writ- 
ing, and in carrying food to his mouth, as well as in other movements of the 
hand. Having on a single occasion submitted to local faradization of the 
arm (some ten months ago), the tremor was much subdued, and. as was 
thought, the fingers and wrist were strengthened. It was not, however, 
until four months ago that the patient returned to put himself under a 
regular course of treatment. 

" Condition of the patient in July, 1876 — General health good; no signs 
of cachexia ; no antecedents of specific taint; no lead poisoning. Suffered 
on two or three occasions, at some years' interval, rheumatic pains and 
neuralgia in the arm and shoulder of the left side, but never in the right 
side, which is the one now affected. The outer appearance of the right 
arm showed but little muscular atrophy; the tremor was inconsiderable; 
the patient could close the hand tightly, but not well grasp larger objects, 
BUch as a tumbler, owing to incapacity to maintain the lirst phalanx of the 
third, fourth, and fifth lingers extended. The wrist was inclined to drop 
forwards (in flexion) and outwards. 

"On inspection it was found that the common extensor of the fingers 
was considerably weakened, most BO in the portion attached to the ring- 
finger, the weakness being manifested both to voluntary and to electrical 
contractility. The same condition existed also, though a little Leas, in tin 1 

extensor of the lit tie linger, and in the radial extensors. The contract ilitv 

was not totally absent, but would vary in degree without apparent cause. 
The disease continued to progress (notwithstanding treatment), tin 



2G4 DISEASES OF THE SPINAL CORD. 

tioDS of the common extensors losing all excitability to my small Gaiffe's 
batti tv. mid the extensors of the thumb being also implicated. 

••The left arm was now examined, and although the patient did not 
notice any weakness in the hand, some deficiency of electric contractility 
was observed in the common extensor, especially in the extensor of the 
ring-finger. The constant current was now nsed for six Aveeks without 
much benefit. The extensor carpi ulnaris is now becoming also affected. 
The patient, however, finds that lie can write and perform various acts 
with the right hand better than before. Within the last week he com- 
plains of some pain along the back of the left forearm when he has been 
holding an object in the air, and feels an inclination to relax his grasp." 

The Doctor also gave a history of hereditary trouble, which was probably 
in one case (the patient's uncle) progressive muscular atrophy. 

I carefully examined the patient, and found that the right arm was that 
most affected. 

Motor power The power of extension of the muscles of the right fore- 
arm was lost completely, and on the left side the power of extension of the 
two middle fingers was to some degree impaired. Flexion was perfect. 

Atrophy. — The following muscles were more or less affected and reduced 
in size. Right forearm : Extensor communis digitorum ; extensor minimi 
digiti : extensor carpi radialis ; extensor longus pollicis ; extensor carpi 
ulnaris ; extensor communis of the left. 

Sensation Slightly impaired on the right side. The teeth of the 

a'Sthesiometer were separated by a space of about ten centimetres before 
two points could be appreciated. This loss was not so great on the under 
surface of the forearm. There was no history of recent pain either con- 
stant or neuralgic, nor were there any dyssesthetic sensations. 

No fibrillary contractions were observed. There was a slight tremor 
in the right hand when voluntary movements were made. Electric con- 
tractility to a very slight degree was observed in the extensor communis 
digitorum when a strong faradic current was applied. The galvanic cur- 
rent also seemed to have some influence upon the weakened muscles. The 
fingers were covered by small flakes of skin, and the nails were crenated, 
irregular, and evidently badly nourished. This trophic defect disappeared 
under the use of the galvanic current. 

Diagnosis. — In the order I name them I proceeded to dispose of lead 
paresis, amyotrophic, sclerosis, cerebral paralysis, traumatic paralysis, and 
progressive muscular atrophy. 

Thai it might be lead paresis seemed reasonable at first, because of the 
loss of electric contractility, the seat of the paralysis, etc. ; but when I bore 
in mind that the trouble was one-sided at first, that there was a subsequent 
invasion of the muscles of the other arm, that sensibility was also impaired, 
and that the patient i\<a\ neither hair-dye nor drank impure water, nor 
wae exposed l<> the dangers of lead poisoning of any kind, I was forced to 
abandon this idea.. A species of spastic contraction drew down the fin- 
gers of the right hand, and there was some cumulative tremor, such as 
characterizes sclerosis (expressed by a gradually increased tremor, aggra- 
vated by will control, and terminating in a species of spasm). This at. 
first led me to suppose thai these might he some degeneration of the Lateral 
columns, hut as 'he tremor^/Hsappeared and there were no other symptoms 
of such degeneration, and especially as there was gradual atrophy and mus- 
cular paralysis, I dismissed this possibility. The loss of electric contrac- 



PROGRESSIVE MUSCULAR ATROPHY. 205 

tility, and the limited field of tin- paralysis, excluded cerebral paralysis ; 
and the fact that the patient had never received an injury, and thai the 
affection was beginning to afiecl tin- opposite group, negatived tie- theory 
of traumatic paralysis. All that was left was the diagnosis of progressive 
muscular atrophy ; and the subsequent appearance of fibrillary contractions 
made me quite sure of my decision. The -low progress of the trouble and 
it- site were, however, doubtful points. The individual had not exerciBed 
any particular member, and as he was a man of leisure, there was no trade 
or occupation in which constant use of the hands or excessive labor was 
required that could account for its origin. The hands preserved their 
contour; there was no atrophy ; no prominent thenar eminences ; nothing 
suggestive of the main en griffe. None of the muscles of the back were 
affected, and the deltoids were of good volume and power. The fact that 
others in his family had suffered, that the disease began on one side and 
extended to the other, that fibrillary contractions were present, that sub- 
sequently I was enabled to get slight, and afterwards stronger contractions 
of the paralyzed and atrophied muscles, determined me in my diagnosis of 
this anomalous case. I call it anomalous, because 1 have been taught, and 
my own experience convinces me, that this is a. very rare seat of progres- 
sive muscular atrophy. Protean as is the malady. I have not seen para- 
lysis of the extensors, as a primary symptom, in any one of the twenty- 
eight cases of the affection I have met with from time to time. 

In lead paresis the invasion is rapid, the paralysis the same, and the 
atrophy is secondary, which is not the case in the wasting palsy. There 
is sometimes the lead line or lead colic, and electric contractility is im- 
paired from the first. From traumatic paralysis it can be diagnosed by 
the irregularity in situation of the muscles atrophied. In traumatic 
paralysis we may look for atrophy of groups of muscles which are sup- 
ported by a common trunk, as well as loss of electric contractility and 
secon da ry a t re >j >1 iy . 

Prognosis. — Occasionally the disease may be arrested or cured en- 
tirely, and this fact seems almost incredible when we bear in mi ml its 
organic character. I have succeeded in arresting the disease in ten cas 3, 
and think that, when then 1 is the least muscular response to electricity, 
there is still a chance for improvement, if not complete relief. This 
IS, of course, in proportion to the extent of invasion. If the atrophy be 
Confined to the muscles of one forearm, there need be no reason to give a 
bad prognosis. The majority of cases, however, go on to an unfavorable 
termination, and perhaps one reason i-. that patients delay BO long to seek 
medical advice, considering their disease to be rheumatism, and amenable 
to domestic treatment. 

Roberts 1 thinks that the prognosis is bad when hereditary predisposition 
can be traced, or when the upper and lower extremities are both impli- 
cated. 

Treatment. — I know of no other remedies than those which are local 
(excepl when a syphilitic taint i- bu spec ted). Electricity i< one of these; 

1 Art. Wasting Palsy, Reynolds's System of Medicine, ml. ii. p. ' : 



266 DISEASES OF THE SPINAL CORD. 

muscular rest is the second when the affection has followed overuse of 

certain muscles. 

The galvanic current from not less than twenty cells should be used, 
one electrode being placed over the nucha, and the other in the supra- 
clavicular space. Seances of ten minutes every day cannot fail to do 
good. In addition to this, the faradic current should be employed for the 
muscles themselves. I have tested the plan of Duchenne, who recom- 
mends painful and powerful currents, and have not found it successful. I 
prefer rather to make each muscle contract several times, and then allow 
it to rest, and repeat the operation some minutes afterwards. Violent 
electrization, I am convinced, fatigues these crippled muscles, and does 
more harm than good. Yivian-Poore and Fagge 1 have had wonderful 
success with this agent, and have cured a number of apparently hopeless 
cases. I have been induced to try the "rubber muscle," as arranged for 
lead paresis. This forms an admirable means for support of the hands, 
should the extensors be affected, as was the case in the history I have just 
related. In every case it is well to insure perfect rest, if possible, for all 
affected muscles. If the muscles of the shoulder be so atrophied as to 
allow the arm to drop, it is well to arrange some contrivance to sustain 
its weight, and relieve the strain upon the affected organs. Sulphur 
baths and mineral waters have been recommended, and in some hands 
have been successful. 



PARTIAL FACIAL ATROPHY. 

Synonyms. — Trophic neurosis of the face (Romberg) ; Laminar 
aphasia (Lande) ; Progressive facial atrophy (Hammond). 

The disease was first described by Romberg 2 in 1 8^7, and subsequently 
by Lande, 8 Samuels, 4 Bergson, 5 Eulenberg, 6 Fremy, 7 and Moore, 8 who 
have all reported cases. Eleven examples were collected by Lande alone, 
who studied the disease quite faithfully. The oidy American case, besides 
those reported by Hammond 9 and Bannister, 10 was presented at a meeting 
of the New York Society of Neurology, December 20j L875, by Dr. Wil- 
liam II. Draper," and I then had the opportunity of examining her, and 
subsequently obtained a photograph, a copy of which is presented. 

1 London Practitioner, Dec 1868. 

2 Klinische \Y;ilirenmng uikI Beobachtungen, Berlin, 1851. 

3 These de Paris, L868. 

1 Der Tropisehen Nerven, Leipzig, 1860. 

5 Dii Prosopodysmorphia sive Nova Atroph. Fac., Berlin, is?:;. 

1 Lehrbueh der Funct. N. k.. Berlin, is? I . 

: BStude critique de In Trophone'vrose faciale, Paris, 1872. 

H Dublin Quarterly Journal, L852. 

" Op. cit., p. 548, '/ * </. 

" Journal of Nervous and Mental Diseases, ik?7. 



11 Reported in Am. Psychological Journal, Feb. 1*7<;. 



PARTIAL FACIAL ATROPHY. 261 

The patient, who was u stout, hearty Irish girl, aged 18, and without 
any hereditary predisposition, presented herself, with the following his- 
tory: About two years ago the muscles under the body of the lower jaw 
of the left side began to diminish in size, and after a few months there 
was gradual extension of* the atrophy, so that finally a district bounded by 
the symphysis of* the lower jaw, angle of the nose, and middle of the 

Fin. 38. 




Partial Facial Atrophy. 

upper lip in front, lower edge of zygoma above, and ramus of the inferior 
maxillary behind, became entirely affected. The skin is bound down to 
the periosteum of the lower jaw, and is shiny, tense, and white. There 
never has been pain of any kind, but the only sensory alteration occurred 
in the beginning, when a slight itching was felt. There is no anaesthesia 
anywhere, not even in the tongue, one side of which is markedly atro- 
phied. In the beginning there were occasional cramp-like pains about the 
insertion of the masseter muscles on the left side, but none on the other. 
There was slight paresis in some of the muscles involved. 

In twelve Continental cases collected by Draper, eight of whom were 
women and four men. the atrophy appeared in one at three years of 
and in another at twenty-two years of age. The beginning of the atrophy 
in these cases was not always the same. In two instances it began by 
pallor; in the others by red spots, next followed by loss of color: and 
finally there was a parcliinent-like appearance of the skin. Sensibility 
was not lowered in any instance, but in two there was itching, as in 
Draper's case. In one the disease w;i-; preceded by Bpasms of the mas- 
seter muscles ; in six the tongue was atrophied ; in one the tonsil: and in 
the rest the soft palate. In two cases there was deafness. In no case 
was there affection of the secretion of saliva; but in one there was dimin- 
ished pulsation in the carotid of the affected side. In Done were there 

indications of central disease. The cutaneous changes alluded to are 
peculiar, and a variety of trophic alterations may attend the disease J 



268 DISEASES OF THE SPINAL CORD. 

sucb, for instance, as falling out of the hair, or changes in color and the 
appearance of eczema. The atrophy is sometimes quite extensive, involv- 
ing the bones, which, in some cases, have been measured and found to be 
greatly reduced in size. Electric contractility of the muscles does not 
appear to be in the least diminished. The temperature of the affected 
side is generally lowered, but there is no diminution of sensibility. The 
left side appears to be the more common seat of the disease, and of the 
twelve cases already alluded to, but one was of the right half of the face. 

Causes In some of the reported cases there was a history of pre- 
vious intermittent fever, scarlatina, and scrofula, and in one case there 
was a traumatism, but it is a question of great doubt whether these were 
concerned in the development of the atrophic condition. It seems, how- 
ever, to be a disease which is more common between the tenth and the 
thirtieth year. 

Pathology Undoubtedly this disorder is one of a trophic nature, 

and of central origin. The absence of motorial or sensorial disturbance 
makes this theory very plausible. Hammond considers the unilateral 
character of the affection a strong argument against the theory of its peri- 
pheral origin. If the lesion were of a peripheral character, it is highly 
probable that both sensation and motion would be affected, for I cannot 
conceive a diseased condition of trophic filaments alone when they are 
found in company with other sensor and motor filaments, as in a nerve- 
trunk which is diseased. This hypothesis seems more reasonable when it 
is borne in mind that the parts atrophied are supplied by other cranial 
nerves than the seventh. I therefore think that the theory of degeneration 
of the trophic cells of the bulb is a much more acceptable one than that held 
by Bergson and others. Eulenberg considers it to be essentially a lesion 
of the fifth pair, in which opinion he is sustained by Romberg, Samuels, 
Charcot, and Yulpian. Against this, it may be urged that lesions of the 
fifth nerve of a trophic nature are generally followed by corneal changes, 
which, as far as I can learn, have never been witnessed in this disorder. 

Diagnosis Progressive muscular atrophy and facial paralysis seem 

to be the only diseases with which that under discussion may be con- 
founded. Against the first it may be said that there are never the pecu- 
liar Cutaneous changes of the disease under discussion — no dark spots, no 
falling out of the hair, no tightness of the skin; and, moreover, this site 
of atrophy is very rare in progressive muscular atrophy. Facial paralysis 
i- nearly always of sudden appearance, and the muscles lose their electric 
contractility. 

Prognosis. — As far as I can learn no deaths have been reported, and 
no cures by drugs. From it- progressive nature (and particularly if we 

concede it to be a central disease of a degenerative character) the prog- 
nosis must 1"' bad. though two or three cases have been related, however^ 

in which there was an arrest'nf the atrophy without any treatment. In 
BelotV case the disease became stationary after a year. 

1 Quoted h\ Draper, Am. Psy. Journal, Feb, L876. 



PSEUDOHYPERTROPHIC MUSCULAB PARALYSIS. 



- 



Treatment Electricity is indicated, but it- use has only once been 

attended by slight improvement in the hands of Moore, 1 who reported a 

ease which was benefited. 



PSEUDO-HYPERTROPIIIC MUSCULAB PARALYSIS. 

Synonyms Myosclerotic paralysis ; Sclerose mnsculaire progress 

(Requin) ; Lepomatosis musculorum luxuriant (Heller). 

Though 6rst described by two Italians, Coste 1 and Gioga, hi 1838, and 
subsequently by Meryon 3 in 1852, the affection attracted little notice till 
1868, when Duchenne 4 presented to the profession a critical analysis of 
thirteen cases. It is hardly worth while t<> enter upon the discussion of 
what has been published since the appearance of Duchenne's book. Suffice 
it to say that Clymer, 5 Ingall, 8 and Webber,' Pepper, 8 S. Weir Mitchell," 
Hammond, 10 Drake. 11 Gerhard, 1 * and Poore^'in America, and Barlow, 11 of 
Manchester, in England, have all reported rases: and I find, in the little 
brochure of the Latter writer, the record- of additional cases by Heller. 15 
Seidel, 16 Wernich," Scheltzemberser, and other Continental writers. So 
far nearly one hundred eases have been reported. 

Symptoms Duchenne details the symptoms in the following order: — 

1. In the beginning feebleness of the lower limits. '2. Lateral balanc- 
ings of the trunk and widening of the legs during walking. 3. A pecu- 
liar curvature of the spine, or saddle-back, both in walking and standing. 
4. Talipes equinus, with an over-extension of the first phalanges of tin' 
toes. 5. Apparent muscular hypertrophy. 6. Stationary condition. 7. 
Generalization and aggravation of the paralysis. 

In illustration of the progress of the disease. I may present a very well 
marked case, which I was permitted to examine by Dr. Y. P. Gibney. 

F. E. M., aged 13. Previous health excellent, her only illnesses being 
whooping-cough at the age of nine months, and scarlet fever a year ago, 
which was followed by some otitis. Her family history is good, as far as 
nervous disease is concerned. Her father died of phthisis, ami her mother 



1 Op. eit. - Quoted by Poore 

3 Trans, of Med.-Chir. Soc. 1852, quoted by Poore and Harlow. 

I De V Electrisation localisee. 

' Clymer's Appendix to Aitkin's Practice, 1868, and Med. Record, 1870. 

Boston Med. and Surg. Journ . - 
: Phil. Med. Times, June and duly. 1871. 
" Photo. Review, Oct. 1871. Op. 

10 Phil. Med. Times, Aug. 29, 1874. 

II Ibid.. Oct. 16, 1875 (previously reported l.\ Mitchell). 

12 X. Y. Med. Journ., dune. 1875. 

13 On Pseudo-hyper. Paralysis, Liverpool and Manchester 
Reports, \ ol. iv. 

" Deutsches Archiv fin- Klin. Med., nun. i. 1865. CentralblaJ 

10 Deutsches Archiv fur Klin. toin. ii., -ted h\ 



it.. M i'd. 



Med. and Sun?. 



t. L867. 



2T0 DISEASES OF THE SPINAL CORD. 

is alive and healthy. Her ancestors were long-lived people. She tells us 
of an injury received in 1870, a boy having tired a brick at her, which 
struck her in the small of the back. No fever or pain preceded her 
present trouble. Her disease was of gradual development, and the hyper- 
trophy followed the injury which has just been alluded to. At the end of 
six months she found it difficult to go up stairs, and her helplessness in- 
creased until the time of admission into the Hospital for Ruptured and Crip- 
pled April 7, 1870. The following history was then taken: Complexion, 
light; hair, brown; eyes, hazel. She is small for her age, though well 
developed. She stands with abdomen prominent, chest and head thrown 
backwards; walks with an unsteady, waddling gait. Upper extremities, 
with exception of elbow-joints, which permit extension beyond an angle 
of 180°, normal. From the sixth dorsal to the sacrum there is a lordosis 
of three inches, the point of greatest incurvation being at the third lum- 
bar vertebra. There is tenderness on deep pressure over the twelfth dor- 
sal vertebra, while both trochanters stand out prominently, and the limbs 
are widely separated, and there seems to be no trouble about the hip- 
joints. There is marked diminution in power of the extensors of the legs, 
preventing her from holding the limb at a right angle to the body. There 
is no marked loss of power in the flexors. But there seems to be some 
loss of power in the anterior foot muscles ; no comparative atrophy of limbs. 
The muscles of the back seem small and poorly nourished. The girl has 
difficulty in arising from, or assuming the sitting posture. The lordosis 
can be overcome by the voluntary act of stooping forward. 

Treatment Spinal brace to restore normal form, and electricity. 

Through the kindness of Dr. Virgil P. Gibney, 1 was permitted to ex- 
amine the patient. I found her to be a rather well-nourished girl. I was 
immediately struck by her gait, which was characteristic of pseudo-hyper- 
trophic paralysis. The feet were planted widely apart, and when propul- 
sion was attempted the whole pelvis was seemingly twisted, and the leg 
clumsily swung forward. The body swayed from side to side, the abdomen 
was prominent, and the shoulders drawn back, so that the extreme lordosis 
described so clearly by Duchenne>was very beautifully shown. When 
stripped, this exaggerated curve was found to be very great. A plumb 
line held at the seventh cervical spine fell about four inches back of a line 
drawn across the upper edge of the sacrum. When my hand was placed 
upon her abdomen, and an attempt was made to force her to stand erect, 
the nates were immediately thrown backwards, and she would have pitched 
forward if not supported. When she attempted to walk, the pelvis seemed 
to be lifted on the side of the limb which was raised, and at the same time 
the corresponding side of the abdomen became quite Hat. Her gait was 
waddling, and she progressed very slowly. There was some spinal ten- 
derness, but no other disturbance of sensibility either in the sound or hy- 
pertrophied muscles. The latter were those of the back of the leg, which 
were much larger on both sides than they should have been, and were 
(piite hard and in marked contrast to the other muscles of the bodv, which 

were flabby and poorly nourished. The muscles of both thighs at the 

inner side seemed to be atrophied, as were all the muscles of the back ; 

but the arms were of norms! contour, and apparently unaffected. There 

\\;i- considerable loss of JSOWer in the lower extremities, the patient being 
unable without great effort to rise from her chair, and when she attempted 
to do so she planted her feet widely apart and approximated her knees. 

The color of the skin was rather darker than it should be, and especially 



PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 271 

on the feet, legs, and hypertrophic! calves was their mottling and imper- 
fect incubation. No difference in tactile sensibility could be noted. Meas- 
urements of different parts gave the following results: — 

About shoulders ........ 29 inches. 

About waist . . . . . . . . 24 

Middle of right thigh 14 

Middle of left thigh i:;_j •• 

Right thigh, just above knee . . . . . .11 

Lett thigh, just above knee . . . . . 12 *' 

Right calf 12 

Left calf ]■> •■ 

A case reported to me by my friend Dr. (*. II. Swazey is the following. 

This patient was also seen by Dr. J. Lewis Smith: — 

J. D., aged 2 years 8 months. Has always been a healthy boy until 
four weeks ago, when it was noticed that he seemed weak in hi> legs, 
especially in the morning, or after sitting awhile. Has not complained 
of any pain. When the child walks, it is in a peculiar wabbling sort of 
a way, with his legs wide apart, and his shoulders carried well back. He 
cannot stand well with his legs close together, but soon totters and falls. 
After he has walked a while this peculiarity of gait is not so perceptible. 
The left leg measures around the calf eight and one-eighth inches, right 
leg around the calf eight inches. Just above the knee left leg measures 
nine and a quarter inches; right leg, same place, nine and one-eighth 
i indies. 

The weakness in the legs has been steadily increasing from the first. 
The grandmother of the child on the maternal side has epilepsy ; the grand- 
mother on the father's side has what the mother calls weak spells, appa- 
rently of an epileptic character. An aunt and uncle on the father's side 
have epilepsy, and there is also a history of syphilis in the family. The 
mother has had miscarriages, apparently due to that cause. The father 
has had eruptions and other symptoms. March 2<Sth commenced treat- 
ment with the faradic current to the muscles, which was continued three 
times a week for six weeks; the disease slowly progressing. At this time 
the patient left off coming, and has not since been Been. 

Weakness of the lower extremities is one of the earliest symptoms, and 
is gradual in its appearance, and not preceded by fever, as is generally 
the case in infantile spinal paralysis. This impairment of power may 
begin imperceptibly, and first attract the attention of the parent by the 
inability of the child to walk at the usual time, or may appear subsequently, 
the child falling frequently or moving clumsily. In Poore's collection of 
85 cases, it is shown that "3 never walked at all. _l never walked well. 
1 is reported as coming on gradually, 52 walked well at first, and in .*> 

cases n<» mention is made of the period of walking." "Of those who walked 

well, 2 began to walk at eighteen month.-, .". at two years, 3 at tw.'-and-a 

half years, 1 at four years. 1 at five, and ."> are reported a- walking late 
and badly." 

Duchenne and Drake reported cases in which convulsions were the be- 
ginning of the disease. Tain in the calves of the legs or back i- some- 
times the first symptom, but i- by no mean- one to expect a- a rule. The 
appearance of the patient is mosl striking. The bellj Beems to be thrown 



272 



DISEASES OF THE SPINAL CORD. 



out, the lumbar curve is increased, and the feet are widely separated. 
When the child attempts to walk, his movements are very much like those 
which we might expect to see in an individual laboring through a quag- 
mire. There is a certain amount of waddling, the legs being separated, 
and the feet planted at some distance apart. In progression the body is 
inclined to the side on which the foot is planted, and there is some jerk 
made in the effort to carry the foot forward. The patient rises from 
the sitting posture with some difficulty, as there is great impairment of 
the extensor muscles of the spine. This weakness is the cause of 
the difficulty in keeping his balance. The next stage of the disease is 
the development of the hypertrophy. Very often this change is an 

Fig. 39. 




The Spinal Curve in PseudoHypertrophic Paralysis. 



early on*', and may follow closely after (lie commencement of the impaired 

motor power. The calves are generally first enlarged, and this enlarge- 
ment may begin with the difficulty in walking, or within a period any- 
where from six months to Several years after the beginning of the disease. 

This enlargement is not, however, always confined to the calves, bul may 
affect the other muscles of" the lower extremities, or even those of the 
upper. The glutei, gastrocnemii, deltoid, and many other muscles have 
ben involved in eases reported by different observers. When the mus- 
cles are Contracted, they stand out quite prominent, and in one of the 

cases reported by Barlow' the child's appearance resembled thai of the 



1 Op. cit., p. 11. 



PSEUDOHYPERTROPHIC MUSCULAR PABALYSIS. 273 

Farnese Hercules. The child is unwieldy and awkward, and though 
there is at this stage some increase in strength of some of the members 
used in locomotion, the child does not seem to have \< rv much motor 
power, for he can scarcely walk. The muscles not bypertrophied may 
undergo an atrophic change, greatly adding to the deformity. In regard 
to the talipes that may be produced, the extensors are agitated by spas- 
modic contractions, which become more aggravated as the attempt to walk 
is persisted in, so that, after a few steps, the child is quite likely to fall. 
The skin may often be greatly discolored in patches just as it is in infantile 
paralysis, and Duchenne has called attention to this ntottliiMj, which 
is due to modified cutaneous circulation, and is seen especially dining the 
later stages of the disease. It is more often confined to the lower ex- 
tremities, and the patches which at first appear as bright red discoloration- 
gradually become more dusky as they are exposed to the air. This mot- 
tling is increased by muscular action, and in certain regions was found by 
Benedikt to be connected with local sweating. The temperature of the 
bypertrophied muscles is higher by a degree or two than those that are 
atrophied ; and in the early stages electric contractility is rarely affected, 
but in the later it is greatly diminished. Of course, this depends upon 
the fatty substitution which the muscular tissue has undergone, for but a 
small amount of normal muscular fibre remains to be called into action bv 
the electric stimulus. 

Causes. — Beyond the question of heredity it is impossible to go in 
our search for causes. One or two cases, however, are mentioned by 
foreign observers in which injury preceded the disease. Kesteven 1 re- 
ported one of these, and in this case the hypertrophy appeared at the 
fifteenth year. 

Poore's table 2 includes the following examples of heredity : — 

"In two cases a maternal uncle and aunt had this disease. 

"In one case three maternal uncles and aunts had this disease. 

"In one case one maternal uncle and one half-uncle had this disease. 

"In one case three maternal half-brothers had this disease. 

"In one case a maternal half-brother, three maternal uncles, and other 
members on the mother's side, had shown the symptoms of pseudo-hyper- 
trophic paralysis. 

"In thirty-seven instances, two or more belonged to the same family. 
It will be observed that it is only on the mother's side that this hereditary 
influence is transmitted; while the disease shows itself' almost exclusively 
in the males. Thus, in a case reported by Duchenne. the mother, while 
phe escaped, transmitted the disease to the children of her marriage. The 
same fact is stated in Foster's east 1 . 

•• In one case a maternal grandfather was hemiplegia 

" In one case a paternal grandfather was insane. 

" In one case a father was insane. 

1 Journal of Mental Science, vol. wi.. April. 1871, p. 18. 

2 hoc. cit. 
18 



274 



DISEASES OF THE SPINAL CORD. 



"Iii one case a father was intemperate. 

"In one case two brothers died of granular meningitis. 

u In one case a brother was an idiot. 

"In fifteen cases of the eighty-five the family history was good. 

••In thirty-three cases no mention of family history is made." 

Pathology and Morbid Anatomy According to Barlow, the 

first examination of the muscles in pseudo-hypertrophic paralysis was 
made by Greisinger and Billroth in 18G5. Greisinger excised a small 
portion of the left deltoid, which was hypertrophied and paralyzed, 
and microscopically examined the muscle, which resembled adipose 
tissue. He found the fasciculi in a perfect state, but surrounded by fat. 
Eulenberg 1 and Conheim 2 found the muscular fibres reduced to fully one- 
sixth their normal size, and in some localities there were masses which 
they supposed were the sheaths of empty sarcolemmae. 

Auerbach 3 found hypertrophy of the muscular fibres, and an increased 
development of nuclei, but no interstitial fat deposit ; but this was in a 
patient who died during the early stages of the disease. BergerV expe- 
rience was identical in an early case. Charcot 5 examined a case (that 
seen by Berger), and found the psoas in a state of primary alteration. 



Fig. 40. 



rT\i 




7W 



Appearance of Muscular Tissue. (Charcot.) 



The primitive muscular bundles were separated by broad spaces of con- 
nective tissue containing cells of a spindle shape, and nuclei. Other 
muscles were likewise affected. The pectoral muscles, and those having 

a sacro-lumbar attachment, contained fewer nuclei, and the internuclear 
spaces were filled with wavy connective tissue. In muscles which had 
undergone still more advanced degeneration, there was some evidence 



1 Axhiv fur Hcilkuiicle, 1865. 

2 Verhandlunggder Berliner Med. (Jcs. i., pp. 101-205. 

:! Yin-how, Arcliiv., vol. iii. p. 224. 

' Deutsche Archiv fur Klin. Med., 1872, p. :ui:5. 

r> Anliiv. de Physiol., etc., is:-^, p. 1. 



PSEUDO-HYPERTROPIIIC MUSCULAR PA HALTS 275 

of fatty deposit. In this case he witnessed three Btagea of degene- 
ration. In the earliest there was atrophy of muscular bundles, indistinct 
longitudinal striae, and sometimes transverse striae. The sarcolemmae were 
filled with a hyaline substance. 

Duchenne 1 denies the existence of empty Barcolemmae, and regards the 
enlargement due to an increase of connective tissue containing fat-cells. 

Diagnosis. — Progressive muscular atrophy -eon- to be the only dis- 
ease with which this condition may be mistaken. If the patient is 
at a time when the conditions of atrophy and hypertrophy coexist, it is 
not always easy to tell whether there is an increase of volume, or simply 
an atrophic condition of some muscles, while others are of normal size; 
but the other symptoms alluded to, the exaggerated lumbar curve, and 
the waddling walk, should settle the question of diagnosis. Progressive 
muscular atrophy is also generally a disease which rarely appears at so 
early a period as does pseudohypertrophic paralysis. Increase of size 
from determination of blood to a muscle, such as that reported by Maun- 
der, 2 and sometimes fatty development, without paralytic symptoms, may 
deceive the incautious. 

Prognosis. — The disease is slowly progressive, and death occurs 
generally from some other disease. Poore reports thirteen deaths. 
Phthisis, pleuro-pneumonia, uncomplicated pneumonia, and croup appear 
to have carried off most of these cases ; and it seems as if pulmonary dis- 
ease bore some special relation to organic disease of the cord, particularly 
when trophic disorder accompanies such disease. In several of the 
spinal affections, especially when the anterior cornuse are affected, there is 
generally the development of phthisis or other pulmonary maladies. The 
deaths that have been reported occurred rarely before the eighth year of 
the disease, and generally between the fourteenth and thirtieth. 

Treatment Duchenne reports two cures by the faradic current. 

This seems to be the only remedial measure that promises anything at 
all. The abolition of fatty food might be recommended, and massage 
should be employed at least every day. The well-known fact that phos- 
phorus produces fatty degeneration should contraindicate its use. 

1 De 1' electrisation localise, Paris, 1872, 3d edition, p. 

2 Med. Times and Gazette, March 27. 1862. 



276 DISEASES OF THE SPINAL CORD. 



CHAPTEK XI. 

DISEASES OF THE SPINAL CORD (Continued). 
POSTERIOR SPINAL SCLEROSIS. 

Synonyms — Progressive locomotor ataxia ; Tabes dorsalis ; Ataxie 
locomotrice progressive; Locomotor asynergia, etc. 

When induration of the posterior columns of the cord takes place, we 
are furnished with a very interesting and striking train of symptoms, which 
are chiefly expressed by pronounced disturbance of the locomotory func- 
tions, and defects in coordination and sensation. 

Symptoms. — After exposure or prolonged dissipation, the individual 
may first notice the commencement of the disease by fulgurating pains 
which dart from the feet up the legs and thighs, and for the time he may 
suppose he has simply neuralgia. These pains are worse at night, and 
may be aggravated by damp or cold weather. They appear and disappear 
rapidly, and Clarke 1 calls attention to their tendency to move suddenly 
from one place to another; remaining located in one spot for some hours at 
a time and then shifting to another. They may shoot through the soles 
of the feet, the inner part of the legs, the knees, or even the thighs. After 
a time, which varies from a few weeks to two or more months, there may 
be a most disagreeable sensory change of a lesser grade, which is confined 
to the feet. When walking, the patient complains that " the ground feels 
a- it' it were covered by fur, or a padded cushion." Sometimes the sensa- 
tion is Likened to that produced by a stocking down at heel, or as if his 
shoe was filled with sand ; or, again, as if he were walking in the air. 
There is no loss of muscular power, nor general loss of sensibility, in the 
preponderance of cases ; but there only seems to be a perversion of tactile 
sensibility, and that only limited to the sense of contact. Heat and cold 
are appreciated, but the shape or size of the cold or warm object cannot 
be perceived by the tactile sense alone. Painful impressions are appre- 
ciated, but tliis is all. Circulation becomes sluggish in the limbs, and 
BUbjeCtive <■< >1< 1 is felt in the lower extremities. If the individual is 
Seated, and the hand <>l* the examiner be held against the sole of the boot 
when the patient's thigh is flexed, it will be found that he is generally 
quite able to extend the leg forcibly, but there may be sometimes a 
Blight LOSS of power in subsequent stages when the anterior parts of the 
cord become affected. In 'the early stages of what may be called the 

descending form, there are various ocular troubles. Amblyopia, strabis- 
mus, or diplopia is among the more common, and it is not unusual 



St. George's Hospital Reports, 1866. 



POSTERIOR SPINAL SCLEROSIS. 277 

to find some atrophy of the optic disk of either one or both eyes. In both 
forms of sclerosis of the cord, ascending as well as descending, it is n< 
sary for the patient to look at the objects which surround him in order 
that he may preserve his equilibrium. It' he shuts \\\< cy<-. In- is apt to 
topple over; and it is utterly impossible for him to walk in fche dark with- 
out holding on to something for support. The patient very often finds 
that when he closes his eyes, as he is about to wash his face, lie i> quite 
apt to pitch forward against the wall. This test is an important one and 
if he is able to stand with his heels and toes approximated and his 
shut, it may be inferred that either his disease has not advanced to a serf* 
ous extent, or that it is not locomotor ataxia at all. The early ocular 
trouble is strabismus, which is an inaugural symptom, and is very often 
accompanied by amblyopia ; and if tin; strabismus be single, the ambly- 
opia will be on the same side. Various paralyses of cranial nerves may 
also follow 7 , and ptosis is not an unusual symptom. Nothnagel 1 publishes 
the notes of a case where hyperaesthesia of the parts supplied by the fifth 
nerve was a prominent symptom. The lost power for Localization i> not 
uncommonly associated with this disease. With closed eyes the individual 
is unable to place the tip of his finger on his nose, or upon any desired 
small point; and, when told to touch the point of a pin held by an ob- 
server, he will be unable to do so, his finger missing the mark. When 
awaking, he is often undecided as to the whereabouts of his legs, or some- 
times feels for a moment that he has none, and needs the aid of vision to 
see that there are such members. The nerve-fibres in the posterior 
columns lose their facility for the conduction of sensory impressions ; 
audit is sometimes several seconds before an impression made at the peri- 
phery is received at the sensorium, and appreciated by the individual. A 
symptom sometimes found in this disease, as well as in myelitis, is the 
sense of constriction which is referred to the waist. The bowels, in the 
early stages, are generally confined; and there is some loss of control 
over the bladder, and constant desire to empty that organ. Romberg 
calls attention to the fact that the stream seems to have no force, but falls 
to the ground on leaving tin meatus. The individual is also troubled 
by erections during the early stages, and there is greatly increased sexual 
power. This, however, is diminished towards the end *A' the disease, and 
in males impotence follows. 

Irritability of temper, occasional mental disturbance, and loss of 
memory are not rare evidences of intellectual failure, and occur at differ- 
ent stages. The electro-muscular irritability seems to be rather increased 
than diminished, and reflex action is usually exaggerated. 1 The locomo- 
torv trouble appeal's quite early, and is one of the most distressing fea- 
tures of the disease. It begins by an awkwardness in progression, and 

1 Berlin Klin. Woch., wii. 1865. 

2 Westphall has recently shown that, when the legs are crossed, it' the tendon of 
the rectus femoria on the aide of the suspended l<"_ r be struck, ac >ntra*jtion of t\\U 
muscle will follow, and the suspended leg will be agitated. In locomotor at 

thi< is not the ease. 



278 DISEASES OF THE SPINAL CORD. 

the feet fly out and are planted with a kind of jerk, the heel touching the 
ground first. The individual totters, and is eventually unable to walk at 
all without support, and the gait cannot be mistaken by any one who has 
(•nee witnessed it. The sense of appreciation of weight also seems to 
suffer to a decided degree. Jaccoud 1 found that this is lost to a great 
extent, and that there is a variation in the power to perceive weights on 
the two sides of the body. In one case mentioned by him, a pressure 
equal to 3000 grammes was perceived on the right side, and 2800 on the 
left. The pains before spoken of generally disappear as the disease be- 
comes confirmed, though they may last throughout. Fibrillary con- 
tractions are occasionally seen ; and, speaking of this, I have often wit- 
nessed a curious phenomenon which follows the use of faradism. 1 have 
noticed that when a muscle of one leg was agitated by clonic contraction, 
sometimes the same muscle in the other leg would be contracted syn- 
chronously with that under electric stimulation : the patient is gene- 
rally timid, and easily disconcerted by any sudden noise or unexpected 
excitement. When crossing the street the desire to avoid being run over 
on the approach of a wagon will produce such demoralization as to prevent 
him from taking another step, and he sometimes falls to the ground. 
There is rarely trembling, unless the disease has involved the upper part 
of the cord, when this symptom, as well as the inability to appreciate topo- 
graphical points, will be marked. The patient is generally worried, anx- 
ious-looking, and wo-begone, and is full of complaints. The disease may 
last for from five to twenty years, and the patient is carried off by tuber- 
culosis or some intercurrent pulmonary affection. Atrophy of all the 
muscles of the extremities generally takes place towards the end of the 
disease, and bedsores and arthritic troubles are annoying and painful fore- 
runners of death. 

Charcot has called attention to certain cutaneous eruptions which not 
infrequently are found with posterior spinal sclerosis, and which are 
usually of a papulous and pustular character, lie mentions the case of 
one person, who, while under treatment at La Salpetriere, presented large 
patches of urticaria, the appearance of which was coincident with the 
attacks of pain. 

The eruptions generally mark out the course of the nerve which is the 
Beat of pain. Hutchinson, however, considers that this arrangement of 
the eruption is usually misinterpreted, and that, instead of the eruption 
following the direction of a nerve-trunk and its branches, the corvmbiform 
distribution of the skin-disease in reality corresponds with the course of 

the small \ essels. 

Charcot and Raymond, 3 in alluding to the disappearance of the heads 

of I ho long bones, relate the case of a woman, aged 52, who had been ill 

lor many years. The autopsy revealed atrophy of the different processes 
of the humerus, femur, tibia, and scapula, with muscular degeneration of 

it fibrous character. In another case there was hip-join! all'ection, and 

great bfittlenese of the bones, which broke when subjected to inconsidera- 



Op. cit., p. 341. 2 Gaz. M6dicale de Paris, Feb. L9, L876. 



POSTERIOR SPINAL SCLEROSIS. 279 

ble force, and afterwards united quite readily. During life the evidences 
of such arthropathies are sometimes numerous. They may be illustrated 
by the following case of Bourcere. 1 

The patient was a woman who entered La Charito April 8, 1*7") • she 
was middle-aged, and presented many of the symptoms of locomotor 
ataxia. These began about ten months before. The left leg seemed to 
be more affected than the right. Three days after admission the left 
thigh and buttock began to swell rapidly, and in a few hours the 
swelling, which was not oedematous in the strictest sense of the word, but 
hard and not painful on pressure, reached its maximum. It extended as 
far down as the knee, where it stopped abruptly. There was no fluctua- 
tion, nor any evidence of pus. The swollen part was almost double the 
size of the other limb, while the leg was shortened, and the foot was to 
some degree rotated outwards. There was also some swelling and hard- 
ness unattended by tenderness in the left iliac fossa. The swelling disap- 
peared almost entirely in a week, when vaginal examination was made, 
and a hard, smooth tumor was discovered, which apparently sprung from 
the pelvic bones of the left side. Pus was soon afterwards detected in the 
psoas sheath above and below Poupart's ligament. She became pros- 
trated, and died on the 6th of May. Alter death, decided osseous changes, 
to be hereafter described, were observed. 

Locomotor ataxia may be associated with progressive muscular atrophy, 
or may sometimes terminate in general paresis of the insane. West- 
phall, Obersteiner, and others have written much upon the relation of the 
two diseases and their possible coexistence. 

Obersteiner, 2 in an excellent paper upon Locomotor Ataxia and Mental 
Disease, considers that mental symptoms are found in the greater propor- 
tion of cases of this disease, and calls attention to the fact that these 
expressions of psychical trouble may be very slight ; still, an acute ob- 
server will know that there is a departure from the normal intellectual 
condition. The patient's character is often changed markedly. I have 
been often astonished at the apathy of an individual, or, on the other hand, 
at his irritability of temper, the violence of bis anger, and his petulance, 
which are more than transitory evidences ; and they are as important symp- 
toms, I think, as neuralgic pains, difficulty of coordination, etc. These 
changes were well displayed in a patient of my own ; in health he was a 
most amiable, high-minded person; in disease a morbid, bad-tempered, 
whining wreck, lie had been noted for his gallantry on the field during 
the war ; but after this disease had become established, his character seemed 

to undergo a complete transformation, lie wrangled with every one. be- 
came irritable over petty tilings, and made himself generally disagreeable. 
Obersteiner and Simon" both agree that these patients should be exam- 
ined most carefully, and thai the prognosis depends much upon the facts 
relative to mental alteration. The latter says: " II is nol enough thai 
the patient keeps himself quiet, and answers the questions relative to his 

1 Progrfcs Med., Oct. 9, 1875. 

- Wiener Medizinische Woch., No. 29, 

3 Archil/ i iir Psychiatric i. and ii„ 1875. 



2S0 DISEASES OF THE SPINAL CORD. 

age, how lie feels, etc., and does not show marked delusions ;" these are 
not enough to assure us that his intellect is intact. 

In regard to the grave secondary mental changes, Tigges considers 
general paralysis to be a complication, while Obersteiner is convinced that 
the symptoms of this latter disease indicate a progression of the sclerosis 
upwards. He considers the lesions to be identical, and that it is only the 
scat of the change which has anything to do with the symptom expressed. 
He has also found, in general paralytics who have died, a sclerosis of the 
cord. 

M. Key has observed nine cases of insanity associated with locomotor 
ataxia. In three of these the spinal sclerosis preceded the cerebral trouble, 
and in one the induration had extended from the posterior to the lateral 
columns. He found that the diagnostic difference between locomotor 
ataxia combined with cerebral induration, and simple descending general 
paralysis of the insane, was the walk. In the former the patient could 
not stand with his eyes shut, and in the latter there was no difficulty of 
the kind. "We may also take for granted that the walk of the ataxic is an 
early symptom, and that of the general paralytic a late one. Both are 
examples of defective coordination, and I think the latter is unwisely 
called paralytic. 

The difficulty of turning around is marked in ataxia, and I think it is 
not a prominent symptom in general paralysis. 

A case lately came under my charge where the sclerosis of the cord 
was ascending, and in an incredibly short time the cerebral symptoms 
which indicate the general paralysis of the insane were evident. 

M. F., aged 29 ; United States. On admission to the Epileptic and 
Paralytic Hospital, March G, 187G, I was immediately struck by the 
woman's walk, which was ataxic in the extreme; and on questioning her 
and her husband we ascertained that about two years ago she had neu- 
ralgic pains in the legs and feet; her walking became defective, and 
lias continued so. Her mind was clear up to a short time ago. Her 
pupils are now unequally dilated, the left being the largest. Her lips 
tremble distinctly. Her tongue, when protruded, also quivers; when 
told to keep it quiet, the motion is greatly exaggerated. There is some 
ptosis of the left eye. When told to close her vxv^, she is unable to co- 
ordinate delicate muscular movements. She cannot find the tip of her nose 
with her forefinger by more than an inch. When her eyes are open, she 
cannot touch small points, such as the markings upon my watch-dial. 
When she stands with her eyes closed, she topples over almost instantly. 
When she walks, her toes are thrown out, and she comes down upon her 

heel. Her feel are planted far apart when she attempts t<> stand. When 

walking across the room, she reels, and has difficulty in turning around. 

When attempting to answer questions, she talks slowly, each word being 
Uttered with some effort; the words containing the letters "P'and kk p" 

are explosive, and the lips seem to have a great deal of work to form them. 

The consonants are slumjl over; for instance, the word kk man" is pro- 
nounced » niah;" the " IV are dropped, as are many Other letters. Her 
willing i- \er\ scratchy and irregular, although her husband says she 

formerly wrote an excellent hand. .Mentally she is silly, and laughs im- 
moderately at wrong tines and without c;inse. She has no idea of time, 



POSTERIOR SPINAL SCLEROSIS. 2Sl 

but seems to know what she is saying. She has had several delusions, 
one of which was that she had been home the day before. 

May 12th, two months after admission Her walk is much worse ; no 

urinary or other difficulty. There is some festination ; pupil- -till uneven. 
The difficulty in speech has markedly increased. Her tottering walk 
is striking. We at first thought she had syphilis, but this is not bo. 
Being unmanageable and restless, she was transferred. Here undoubtedly 
was an ascending condition, beginning with the pains and gait of loco- 
motor ataxia, and ending with several early symptoms of general paralysis. 

Charcot 1 has described a peculiar train of symptoms accompanying the 
pains of the earlier stages. These are the crises gastriques, which are 

expressed by pains which begin in the groins, and run up the abdomen on 
either side, finally becoming fixed at the epigastrium. They are violent, 
and occur during the exacerbations of lancinating pain in the lower ex- 
tremities. During the time they last, there is violent palpitation, vertigo, 
and vomiting, the latter symptom occurring without relation to the con- 
dition of the stomach. If there be no food to be expelled from that organ, 
there may be a quantity of frothy and bloody liquid ejected. These crises 
last two or three days, and disappear quite suddenly. Some observers 
have noticed the appearance of ptosis during their existence, which 
gradually disappears ; and Stewart 2 has seen several cases in which these 
symptoms varied, and instead of there being pain which started from the 
groin, there was deep-seated pain in the dorsal and lumbar regions. 

Reynaud has called attention to a species of renal neuralgia which is 
not at all an uncommon complication. One of his cases, which was mis- 
taken for renal colic, presented lumbar pain, vesical tenesmus, retraction 
of the testicle, and other suggestive symptoms. There was temporary 
cessation after a few days, but a second and third attack followed. Char- 
cot and other French writers have alluded to various additional visceral 
disorders, as found with this as well as other organic spinal diseases, and 
the functions of the kidney are sometimes greatly disturbed. I do not 
think that sufficient attention has been paid to forms of hysteria which 
resemble locomotor ataxia. These, I believe, are the cases which are 
cured. Isnard 3 has extensively considered the functional form ; and Webb, 
of Philadelphia, has reported a very interesting case of genuine hysteria 
which counterfeited the organic disease so closely as to lead to a primary 
error in diagnosis. 

Causes Dissipation has much to do with the development of this 

terrible disease, while onanism and venereal excesses, esj ecially, play ;m 
important part ; so we may expect to find it among men about town, hard 
drinkers, and other people of bad habits. Injury, exposure to rain and 
cold, syphilis, and protracted mental excitement, favor it- origin. Some 

sudden exposure, such as a fall into the water, or a night in the rain, may 
be the exciting cause, and several of ni\ cases had BUCh a beginning. 

1 Op. cit. i Med. Times and Gazette, Oct 7. 18< 

8 L'Union Medicale, 181, 134, 185, 137, 141, 142, 1862. Abet, in Lancet, 

Sept. so, is::.. 



282 DISEASES OF THE SPINAL CORD. 

Rosenthal 1 reported sixty-five cases, forty-six of which were males and 
nineteen females ; and of this number thirty-one were traced to libidinous 
, x , -, ssegj seven to exhaustion, and twenty-seven to cold and exposure. 
The youngest of these patients was nineteen, and the oldest sixty-eight. 
The ages at which the disease appears is rarely before the thirtieth, 
and never after the sixtieth year. Heredity seems to have much to do 
with its development. For instance, N. Friedrich 3 reports six cases which 
occurred in two families ; and two of these patients were males, and four 
were females. The heads of the families were drunkards. Syphilis, as I 
have said, is sometimes at the root of locomotor ataxia, and perhaps is 
the most fortunate cause to discover, as it greatly alters the prognosis of 
the disease. It must be understood that the lesion is purely syphilitic ; 
and the symptoms result simply from the presence of a gummy infiltration 
or tumor in the posterior columns, and not from any induced sclerosis. 

Morbid Anatomy and Pathology — The cord of the ataxic, when 
cut into, will present an appearance which is distinctive. The posterior 
columns will be found to be more gray and dark than they should be, and 
there may be hard deposits on either side of the posterior fissure. Be- 
neath the microscope the peculiar thickening of the connective tissue will 
be found to have taken place at the expense of the nervous elements. 
Lockhart Clarke thus tersely describes the changes that take place : " The 
morbid anatomy of locomotor ataxia consists chiefly of a certain gray 
degeneration and disintegration of the posterior columns of the spinal cord, 
of the posterior roots of the spinal nerves, of the posterior gray substance 
or cornua, and sometimes of the cerebral nerves. A variable number, 
and frequently in the latter stages of the disease nearly all the fibres of 
the posterior column and posterior roots, fall into a state of granular 
degeneration and ultimately disappear. Usually the posterior columns 
retain their normal size and shape in consequence of hypertrophy of con- 
nective tissue which replaces the lost fibres. 

" In this tissue, at wide but variable intervals, lie imbedded the remaining 
nerve-fibres with the d&bris of their neighbors in different stages of disin- 
tegration. In some places they are severed into small portions, or into 
rolls or lobular masses formed out of the medullary sheaths of white sub- 
stance, whichhas been stripped from their axis cylinders. In other places 
they have fallen into smaller fragments and granules, which are either 

aggregated in the Line of the original fibres Or scattered at irregular dis- 

tances. Corpora amylacea are usually abundant, and oil-globules of dif- 
ferent size- arc frequently interspersed among them and collected into 
groups of variable shape and size around the bloodvessels of the part. I 
am inclined to believe from my own investigations thai in the course of 
the disease the posterior cornua of gray substance are more or less affected^ 
and it appears to me to be ^question whether they are not the firsl parts, 
or at least among the firgl parts that are morbidly changed. I have also 

1 Wien, Med. Woch., 1869, No. 251. 

2 Yin-how's Archiv, xxvi. pp. 391, 488. 



POSTERIOR SPINAL SCLEROSIS. 






shown that in some cases the deeper central parts of the gray subsl 
are more or less injured by areas of disintegration. These latter lesions, 

however, are not essential to the production of locomotor ataxia, the 
peculiar symptoms of which depend solely on lesions of the posterior 
columns of the posterior nerve-root-, and probably of the posterior cornua. 

The cases in which they occur may he considered as mixed cases, partak- 
ing of the nature of locomotor ataxia and common spinal paral 
Charcot and Vulpian consider sclerosis of fillets or columns of Gall t<» be 

the essential lesion of the disease under consideration. These occupy the 
space on either side of the posterior fissure, and from them pass the most 
internal sensory roots. I do not think, at this Btage of Our knowledge, that it 
is possible to make the distinction between Bymptoms indicative of scl< 
of the columns of Gall and of other parts of the posterior column. It has 
been shown that the nerve-roots themselves need not necessarily be 
affected, although the cornua may be degenerated mosi completely. The 
sclerosed parts of the cord in this disease are more commonly the Lumbar 
and lower dorsal, although the cervical portion may be invaded a- well. 
The case mentioned by Nothnagel presented sclerosis of the entire poste- 
rior columns. The bones undergo remarkable change-, and after death 
the result of such arthropathic alterations maybe seen in atrophy, exfolia- 
tion, shortening, and destruction of their articular surfa 

The appearance of old fracture is admirably shown in Fig. II. 
which is taken from Charcot. The cranial nerves are not rarely affected, 



Fio-. 41 




Api>c;irauce of Trophic Bone Changes in Locomotor A- i 



their course being sometimes interrupted by patches of degeneration. 
The induration attacks the periphery first, and extends to the centre, and 
the changes begin at the point of origin of the nerve and progress towards 
it- distal end. The optic disk i- uearlj always found to be atrophied and 
blanched, but there seems to be no change in the site of the retinal 



284 DISEASES OF THE SPINAL CORD. 

sels. There are often evidences of injection of the investing membranes of 
the cord or actual meningitis, and six cases which were reported by Fried- 
rich presented opacity, and thickening of the pia mater, which was adherent 
to the cord, and I doubt if there are many examples in which some form of 
meningitis has not existed at some time or other. Charcot 1 alludes to 
the gray degeneration of the optic nerves as an evidence of amaurosis that 

prominent a symptom, and he calls the pathological condition "nev- 
rite parenchyniateuse." 

Much of the interest belonging to this disease is connected with the 
phenomena of incoordination, and a lesion that may affect the integrity of 
the organs intended for the transmission and reception of visual, auditory, 
or tactile impressions will result in a loss of equilibrating power. Accord- 
ing to Ferrier, the apparatus provided for the maintenance of equilibrium 
consists of: 1, a system of afferent nerves ; 2, a coordinating centre; 3, 
efferent tracts in connection with the muscular apparatus concerned in the 
action. Of course lesions of one or all of these parts must result in a loss 
of balancing power. Perhaps the most important factor in the preserva- 
tion of equilibrium is tactile sensibility. The frog, deprived of his skin, 

the power of coordination, for the coordinating centre is deprived of 
the exciting organ from which impressions are transmitted. So, too, may 
this loss follow sudden destruction of one of the peripheral organs of spe- 
cial sense. As has been shown by Yolkmann, the exposed ends of the 
nerves are not sufficient to transmit the sensory impression, but it is neces- 
sary that their cutaneous terminations shall exist. When the tactile sen- 
sation in the ataxic is blunted, or the impressions are interrupted in their 
upward course, as has been held by Schiff, we have a loss of coordinating 
power which is a striking feature of locomotor ataxia. It is not neces- 
sary for consciousness to enter into equilibration and coordination, for, as 
we well know, many acts are purely spinal in character, and become auto- 
matic to some degree; and walking is notably one of these acquired 
automatic movements. Acephalous monsters have performed a number 
of acts which were strongly reflex ; and animals from whom the brains 
hare been removed are able to coordinate to a certain degree after the 
firsl -hock of the operation has passed by. In the disease under consider- 
ation consciousness enters to a decided extent when the harmony of the 
coordinating centres is lost. This consciousness is exhibited in vertigo, 
and is exerted in the ineffectual etlbrt to regulate the actions of the limbs. 

the brain endeavoring to supply the lost automatic sense. Broadbent 9 

Considers thai there are two coordinating centres; one in the cerebellum, 

and the other, a- 1 have stated, in the cord. Vision holds the same 
relation to the cerebellar coordinating power that tactile sensibility does 

to the cord centre. For instance, a tight-rope walker would fall were 
il not for the aid of vision, although the tactile sensibility becomes so 
perfectly educated thai it ma/ take the place of the eves in enabling the 

1 Lecona sur le Syst. nerveux, 2eme serie, i fascic. 

•' Brit. Med. Journal, April, is;;,. 



POSTERIOR SPINAL SCLEROSIS. 



2*5 



Fin-. 42. 



performer to regulate his actions. 1 The tactile sense is of a lower grade, 

and when this tails the individual, as is the case with the ataxic requires 
more than ever the aid of vision. In the normal condition he may close 
his eyes, and still be able to walk in the dark with some ease ; bul if the 
tactile sensibility be affected, as it is in the disease under consideration, 
and if the aid of his vision be denied him, he is utterly helpless to regulate 
his muscular movements. In the daylight he still has the power of help- 
ing himself, for vision comes to his assistance. Jn health this delicacy 
of coordination may. be trained to a marvellous degree. I ha\c repeatedly 
witnessed the feats performed by a French juggler, which illustrated the 
nicety of appreciation of weight it is pos- 
sible to arrive at by practice. He would 
throw into the air a heavy cannon ball and 
a pellet of paper, alternately catching them 
and tossing them up again, and the mus- 
cular movements were regular and harmo- 
nious, and indicated no effort whatever. 
In locomotor ataxia this power of appre- 
ciation is sometimes lost to a marked 
degree. To the ataxic individual a four- 
pound weight seems no heavier than one 
of two pounds would if he were in nor- 
mal condition, and if his muscular move- 
ments were properly coordinated. 

The arrangement of the sensory fibres 
of the posterior column is such that a 
lesion of either the white or the gray mat- 
ter itself must interfere with the conduc- 
tivity of sensory impressions. Lockhart 
Clarke's histological researches have 
thrown much light upon the subject. 
According to him, the posterior root-fibres 
ent<r the cord in three directions, some 
pacing in at right angles to the longitu- 
dinal fibres of the posterior column, then 
passing across the same as well as the 
gray substance, then bending and continu- 
ing longitudinally downward, next pass- 
ing into the gray matter of the anterior 
cornua, and finally terminating in fasci- 
culi which intermingle with the fibres of 
the anterior loot-, or extend into the an- 
terior columns. Other fibres (those of 

The < ouric ol Pwterl i 

the second class) run across the posterior (ciw 




1 1 have no doubt some of mv American readers have witnessed the perform. 
unci' of a tight-rope walker, who goes through hi- feats of balancing and walking 
with bandaged eyes, meanwhile perfectly preserving his equilibrium. 



2S6 



DISEASES OF THE SPINAL CORD. 



columns, or cross to the other side of the cord in the posterior commissure, 
or extend deeply into the posterior columns of the same side; and others 
pass forward into the gray matter of the anterior cornua. The third kind 
of posterior spinal roots enter obliquely ; and certain fibres pass upwards 
and downwards, and become associated with fibres above and below them. 
The remaining fibres take an oblique course, and run upwards and dow r n- 
wards, the greater number taking the former direction and passing finally 
into the gray matter. It will be seen that a lesion affecting the pos- 
terior columns of the cord will destroy the communication of the nerve- 
roots with the gray matter, or press upon the sensory fibres, causing peri- 
pheral pain. The communication with the parts above is destroyed, and 
should the sclerosis involve the anterior gray matter there may be paralysis 
and atrophy. A favorite theory, accepted by many writers, is that which 
considers that there are numerous centres of coordination in the cord, 
which are connected by longitudinal fibres, and that when these fibres are 
destroyed there results a species of incoordination. Dieulafoy 1 divided the 
posterior fasciculi at different heights, but without producing any marked 
defects in coordination, which seems to disprove this theory. 

Diagnosis It is important to distinguish locomotor ataxia from 

chronic myelitis, progressive muscular atrophy, chorea, and cerebellar 
disease. The former disease occasionally resembles ataxia, but with or- 
dinary care no mistakes need be made. The paralysis of the first disease 
i- very marked, and the implication of the bladder and sphincter ani causes 
the patient to void his urine and feces involuntarily, which is not the case 
in locomotor ataxia. The strong ammoniaeal odor of decomposed urine is 
itself almost a sufficient diagnostic mark. There is an absence of power 
in the legs, and none of the pain which characterizes sclerosis of the pos- 
terior columns. Ocular trouble and incoordination are likewise absent. If 
the gait of the two diseases be compared, it will be found that in the for- 
mer the legs will be thrown out with some degree of violence, and the 
heel will come down forcibly. In the paraplegia of myelitis, the legs will 
be drawn after each other, the inner edge of the sole scraping the ground ; 
and there is often a shrug of the body required to bring the feet forwards. 
The walk of the hemiplegic is also different, as one leg is swung forwards, 
the toe describing an arc, or else the foot is advanced in a straight line, 
tin- Bole hardly clearing the floor. Myelitis in its early stages sometimes 
resembles posterior Bpinal sclerosis. The pain in the back, however, is 
characteristic, and the ulterior paralysis and bladder trouble are sufficient 

in themselves to clear ii|) the diagnosis, though the constricting band 

about the waist may excite our suspicion. Cerebellar disease has been 
Bpoken of by RadclinV as a condition thai may sometimes be mistaken 
for locomotor ataxia. The movements are somewhat different, however, 
for the patient rolls and Bways t<> a greater degree, and does not present 

the peculiar jerking gait of the ataxic. Local pain is another symptom 
peculiar to tic cerebellar condition, and vomiting is also suggestive of 



1 These du Concours, 1875. 



Op. <-it., vol. ii. ]>. 688. 



POSTERIOR SPINAL SCLEROSIS. 287 

this affection, but not of locomotor ataxia. Progressive muscular atrophy 

in its earlier stages is apt to be mistaken for locomotor ataxia. The 
wasting of the muscles in anomalous cases may be imperceptible, and the 
unsteadiness of the individual may alone attract attention. This, with 
the pain, may raise a doubt as to the true nature of the malady. Syphilis, 
in some of its forms, also occasionally produces symptoms which arc eery 
much like those of this disease; and there may be paralysis of cranial 
nerves, with pain over the tibia, which may be misleading, when in 
reality no spinal disease exists. 

Prognosis — Among the number of cases reported by various ob- 
servers, I have not found more than one or two well-authenticated cures. 
Hammond has cured some lighter cases, which he does not, I believe, 
really consider to be genuine examples of locomotor ataxia; but others 
have been less fortunate. A peculiarity of the disease is the long inter- 
vals of improvement which occasionally occur ; and the disease may be 
stationary for years, but this is very rarely the case. I know of two 
cases which were so much improved, and remained so well for three or 
four years, that I flattered myself that I had cured them ; but I have 
since seen a change for the worse in both patients. Balfour 1 presented a 
case of locomotor ataxia which he claims to have cured. Pollard- reports 
a case which began rather suddenly, and disappeared quite rapidly under 
treatment. Vidal, 3 Duqueit, 4 and Herschell, 5 all report cures. Vidal's 
patient, a man of 45, recovered in three months, and Duqueit's and Iler- 
sc hell's cases I consider doubtful as regards diagnosis. 

Treatment From the very nature of the disease the treatment 

must be empirical, and no one remedy seems to have done much good, 
although nitrate of silver has been recommended by Wunderlich, Char- 
cot, Yulpian, and others, and has enjoyed great popularity as a remedy. 
Balfour, already alluded to, states that he cured a patient in three months 
by half-grain doses of this salt repeated three times a day. and by the use 
of a foot-bath in which a quantity of common salt had been thrown. The 
feet were also submitted to the influence of a faradic current passed 
through the water by proper appliances. The salts of silver < y VV. 77. 
78, 79) may be used with considerable impunity without discoloring 
the skin, though an unnecessary degree of timidity has been shown in its 
employment. It is well, however, to begin with a quarter-grain dose, and 
it may be increased to a half, or even a grain, thrice daily. One case <>f 
my own was greatly benefited by this drug in combination with DUX 
vomica (F. 79). I have lately tried the phosphate of siher in one-third 
of a grain doses, witli great BUCCess, and prefer it to the nitrate (F. B 
In administering the silver salts it is well to give them continuously tor 
several months, and then permit an interval to elapse before beginning 



1 Brit. Med. Journal, 1875. ; ' Lancet, 1872, vol. i. p. 

3 Gaz. des Hop. 127. 1862. ' L' Union, l •.'•_'. 1862. 

6 Bulletin de Therapeutique, lxiii., Oct. 1862. 

R De I'emploi du nitrate d' argent dans le fcraitemenl de L'ataxie prog 

Bull. (Jen. de Ther., 1862. 



288 



DISEASES OF THE SPINAL CORD. 



again. In the early stages of the disease I prefer the fluid extract of ergot, 
either in combination with the bromide of sodium, or alone (FF. o, G.) It 
certainly seems to control the pain. Among the more efficacious remedies to 
which I may allude is the sulphur bath, which is too little used at the present 
day. and has been praised by the French writers especially. 1 It seems 
to possess, in some cases, powers which are almost marvellous. A small 
lump of sulphide of potassium is to be thrown into the tub in which the 
patient bathes, after which he is to be thoroughly rubbed. In regard to 
electricity, Meyer has reported several cures by the galvanic current. 
Onimus has used the inverse current, and I believe has done some good. 
The indication seems to be that the positive pole should be placed over 
the painful point, if one can be found, and the negative above. These 
cases in which cures have been wrought were, I infer, ataxic conditions of 
a functional character. Faradization of the muscles of the legs and thighs 
seems to comfort the patient more than anything else. Duchenne thinks 
that the muscular anaesthesia is benefited greatly by its use, and that co- 
ordination is improved. Dr. Drinkhard, of Washington,* 2 suggested that 
strychnine, injected hypodermically, is a remedy which should not be lost 
sight of. In one case it promptly relieved the pain. He, however, com- 
pares the dangerous appetite of possible formation to that which grows out 
of the medicinal use of large doses of opium, and fears such trouble. I have 
used the actual cautery to the spine quite frequently, and have found that 
constant revulsive effect kept up for some weeks not only diminished the 
pains, but really improved locomotion. It should be applied down the 
whole length of the back, on either side of the spinous processes; and, after 
the epidermis has shrivelled off, subsequent applications are to be made. 
Belladonna and turpentine are recommended by Trousseau (F. 81), and 
not only relieve the pain, but seem to help any vesical trouble that there 
may be. Should we suspect syphilids, the iodide of potassium (F. 20) will 
be indicated, and a saturated solution should be prepared, and given in in- 
creasing doses till forty or fifty grains are taken three times a day. Above 
all, it must be remembered that nutritious food, cod-liver oil, and moderate 
stimulation arc perhaps more important than medication. 1 have observed 
the oecessity lor quiet and rest. Prolonged muscular exercise is bad, and 
drives are to be preferred to walking. The patient should seek a warm 
Climate, lor this disease is affected by damp cold weather, very much as is 
phthisis, and a cold winter always tells upon the patient. The pains also 
are aggravated by cold and sudden changes, and I find Florida or other 
Soul hern Slates to be tint most comfortable places for these invalids. 
.Much benefil has been derived From the dark room treatment, and I saw 

on.- gentleman who had been greatly improved by a lew months of bed rest 

in a dark chamber. 

Dissipation thwart- any chance of success, and late hours or a debauch 

will produce a relapse some time after encouraging improvement has taken 

place. S<\ual indulgence' (when it i> possible) is likewise to be interdicted. 






1 It hai BCted wonderfully in cases even of long standing, and deserves a 
faithful trial. 

1 Am. .Jour. Med. Sciences, Jnlv, IhTa*. 



ANTERO-LATERAL AMYOTROPHIC SCLEROSIS. 



ANTEROLATERAL AMYOTROPHIC SCLEROSIS.' 

Synonyms Amyotrophic lateral spinal sclerosis (Charcot). In- 

flammation of the lateral columns of the spinal cord, and of tin- anterior 
tract of gray matter (Hammond). 

When the anterior tract of gray matter and the lateral columns of the 
cord are conjointly the seat of destructive changes, we find permanent 
contractures following loss of muscular power in both upper and Lower ex- 
tremities, together with extensive atrophy and subsequent bulbar symp- 
toms. 

Symptoms The disease begins without fever; with loss of power in 

the muscles of the upper extremities, which becomes quite marked after a 
short space of time, and then follows a general atrophy of the muscles ol 
the paralyzed members. In this way the malady differs from progressive 
muscular atrophy, in which one group of muscles, or even a single muscle, 
becomes atrophied before others, and in advance of any paralysis, (liar- 
cot calls this wasting process "atropine en masse." Attendant upon tin- 
paralysis are deformities, and these are highly characteristic of the disease, 
and result commonly from contractures of muscles which are less para- 
lyzed than others, so that the stronger muscles' overcome the weaker. 
The flexors of the hands are commonly affected, and these members are 
flexed and distorted, the fingers being drawn up so that their ends press 
into the palms, as is the case in other forms of post-paralytic contractures. 
The arm may be adducted to the side, and forcible abduction or extension 
is impossible. Pain is usually produced by any violent effort made to over- 
come the deformity, and the physician is obliged to desist. The patient- 
are able, though their muscles are paralyzed and contracted, to perform 
certain limited movements, but the same tremor takes place which we 
observe in other forms of sclerosis when a voluntary effort of any kind is 
made. In the late stages the emaciation is complete, and the appearance 
of the hands resembles that seen in progressive muscular atrophy. There 
are the elevated thenar eminences and the Hat forearms, but the limb is 
still contracted. Charcot alludes to a condition which sometimes affects 
the muscles of the neck, so that they are contracted to such a d< 
that the head is fixed and immovable. He relates a case where tin- mus- 
cles of the inferior maxilla were so contracted a- to greatly interfere 
with mastication. 

The progress of the disease is marked by involvement of the tongue, 
and later by destruction of the nuclei o\' the several cranial oervec 
that various losses of special function rapidly follow, and death termi- 
nates the patient's sufferings. The inferior extremities are paralyzed in 
their turn, and are the seat of contracture- which resemble in some re- 
spects those of the upper extremities, so that the patient's condition i- one 

1 I prefer this compound title. Bfl it obviate- confn-ion and more definitely I I 

presses the scat of the <li>case. 
19 



290 



DISEASES OF THE SPINAL CORD. 



of helplessness. The legs become rigid when he attempts to walk, and 
are agitated by tremors so that he is obliged to desist. The contrac- 
tures in the lower extremities are much more marked than in the upper, 
and when finally the victim seeks his bed he presents a most abject and 
pitiable appearance, the legs being twisted and contracted so that he re- 
quires the services of an attendant, as he is utterly unable to do anything 
for himself. 1 Fibrillary tumors may be present just as in progressive 
muscular atrophy, but are not so constant as in the latter disease. The 
symptoms which usually herald the approaching end of the disease are 
those which indicate invasion of the bulb. Paralysis and atrophy of the 
tongue, vermicular movements of that organ, and affections of speech, 
are among these, and the orbicularis oris and facial muscles are next 
attacked, when there may be drooling of saliva and other indications of 
bulbar degeneration. In short, the symptoms are very much like those 
of bulbar paralysis. Sooner or later the pneumogastrics are implicated, 
and death follows. The disease runs its course in from six months to 
three years. 

I have been so fortunate as to see one case of this disease, the notes of 
which I append. 

E. S., laborer. About one year ago he first noticed an awkwardness in 
holding his spade, and when engaged in the excavation of a cellar he was 
unable to throw up the dirt, and at the same time felt unpleasant formi- 
cations and cramps. These became so distressing that he applied lini- 
ments to his wrist and arms, but without any relief whatever. He con- 
sulted a medical man, who tried electricity, but without any good effect, 
and, after passing two or three months without treatment, he came to me, 
and I was enabled to make a diagnosis almost immediately. Both hands 
were strongly flexed, and the muscles were greatly atrophied. The index 
finger of the left hand alone escaped contraction. There was some rigid 
contraction of the forearms, while thl? arm was carried upwards and for- 
wards by the muscles of the shoulder and thorax, and there Avas no move- 
ment at the elbow or wrist. Fibrillary contractions were observable in 
the triceps, pectoralis major, and biceps. When I endeavored to straighten 
the arm Ik; suffered great pain, and begged ine to desist. There seemed 
to be no involvement of the lower extremities, and the patient walked 
withoul embarrassment. 

Seeligmullcr 2 saw several curious eases, which were not only valuable as 
instances <»i heredity, but which illustrated the course of the disease. 3 

The eases came under the observation of Keeligmullcr in January, 187(1. 
The. family history, which was carefully inquired into, was remarkably 
good, with one Significant exception — that the patents were firsl eousins. 
There was DO evidence! of syphilis. Seven children — six girls and one 
boy — were I he result of the marriage. Of these, the eldest, aged eleven, 



1 There u never entaneojH anesthesia, the bladder and rectum are never 
affected, and there is n<> tendency to bedsores (Charcot). 



i Deutsche Bdedicimsche Woch., April 22 and •_>:>, into. 
a London Medical Record, June 15, is7G. 



ANTEROLATERAL AMYOTROPHIC SCLEROSIS. 201 

was quite healthy; the second, aged ten, was in an advanced stage of the 
disease; the third was, if anything, worse still, bul was not -ecu; the 
fourth, a boy, aged six years and nine months, was in the middle Btage; 
the fifth and sixtli were healthy; and the seventh, aged one year and nine 
months, was in the first stage of the affection. The disease began in a 
similar way in all. Strong and healthy when horn, they continued bo up 
to the age of about nine months, when a change took place. Able pre- 
viously to sit up without trouble, they began to lose this power, and would 
fall to one or other side; later, tin; head and chest sank forward. At the 
age of two years attempts were made to teach them to walk, bul their 
efforts resembled those of an infant six months old. This wag exemplified 
in the youngest patient, who, when supported under the armpits, made 
jumping movements, the legs being raised from the ground simultaneously. 
Subsequently the children learned to support themselves with difficulty 
against a chair, but even this power Mas lost again, 'flu- boy had lately 
been rapidly losing ground in this respect; he could still, however, drag 
himself about in bed, and, by means of a specially constructed chair on 
wheels, could walk. The two eldest children, when supported in the 
upright position, could not put one foot before the other; even when lying 
down, they were unable to move, the upper extremities being uselee 
supports. The youngest girl coidd sit for a short time on tin; table, but 
cried all the time, and soon fell to one side; she sat with her head and 
chest inclined forwards, the spine equally curved, and the thighs greatly 
abducted; when on the lap, however, she could move her arms and leg- in 
all directions. 

Contractions at the joints were present in a high degree in the three 
eldest. In the eldest girl the hands were adducted and pronated; pain 
was produced by attempts at passive supination, and the hand, when re- 
leased, jerked back to its old position. The fingers were rolled in towards 
the palm, but she could still extend them, though very gradually and with 
great difficulty. The grasp was still perceptible; the right better than 
the left. The elbows were slightly bent, and nearly fixed. The b 
were half Hexed, but could, with great force, be moderately extended or 
flexed still more, though on leaving them they sprang back with a jerk. 
The feet were in the position of advanced equino- varus ; the tendines 
Achillis were perfectly rigid. All attempts at passive movement produced 
considerable pain. The boy was put under the complete influence of 
chloroform, and the rigidity of the joints then SO increased that the whole 
body could be raised from one leg and held out like a piece of wood. The 
youngest girl had so far no contractions. 

Atrophy of the muscles was marked in the two eldest under observation. 
With the exception of those of the face, it was evenly spread over the 
whole system. The wasting in the case of the girl was considerabl 
that the head seemed too large for the attenuated neck, and was moreover 
unsteady. The parents were confident that in all three the wasting was 
not \ isible for some time after the loss of power >how ed it-elf. 

In the eldest child the reaction of the tibial and peroneal nerves was 

normal with both currents ; but the irritability of the muscles was decidedly 
lowered everywhere. Of those on the back of the forearm, the Bupinator 
longus alone responded promptly. In the youngest girl, faradic excita- 
bility of both nerves and muscles was perceptibly lowered in all extremi- 
ties, but especially in the left lower. vNalxauic e\cilahilil\ wafl 1"^' 
in tin- same wav, and in the tibial nerves was almost nil. Ordinary rt \ 



292 



DISEASES OF THE SPINAL CORD. 



irritability not increased. That of the tendons, however, was present in' 
a high degree in all. Fibrillary contractions were markedly present in 
the eldest girl, and could be produced by simply blowing on the skin. 
Sensibility was normal in all. 

Of the symptoms noticed by the parents, that which made its appear- 
ance last \\as i lie gradual loss of the power of speech. Thus, in the two 
eldest girls, this was tolerable until their sixth year, when it became less 
and less distinct, until finally only inarticulate nasal noises could be made. 
In the girl, the lips, soft palate, and uvula were all paralyzed, and the 
tongue lay in the mouth like a mass of dead flesh; its tip could be ad- 
vanced only as far as the teeth. In the boy the same symptoms were 
present, but in a somewhat less degree. The youngest child could say a 
few words, but these had a slightly nasal tone. Swallowing in the two 
eldesl girls was difficult; in the boy, tolerable. The form of the skull was 
unusual in all, but especially so in the eldest. It was very broad between 
the parietal eminences, and very undeveloped in the frontal region. The 
forehead was low, and the head appeared altogether too small for the face 1 . 
In the oldest girl the features were coarse ; the expression was vacant, 
but usually amiable; the pupils were much dilated; the saliva flowed con- 
tinuously out of the half-opened mouth ; and, indeed, her general appear- 
ance Mas that of an idiot; though, in point of fact, the intellect was very 
fairly developed. The faradic excitability of the facial muscles was de- 
cidedly increased; the galvanic was normal. 

Causes No definite causes are known, though exposure is believed 

to have much to do with its origin, and Charcot's and Hammond's cases are 
thus accounted for ; but we may also consider that dissipation and hereditary 
influences play an important part in the etiology of the affection. It is a 
<li.-< tase which rarely occurs before adult life, as far as we are enabled to 
judge from the limited number of cases which have been reported. 



Fijr. 43. 




A. AtitiM-') Lateral sclerosis 




Posterior spinal sclerosis. (After Charcot.) 



Morbid Anatomy. — To Charcot belongs the credit of having made the 
distinction between progressive muscular atrophy and lateral amyotrophic 
sclerosis. Previous to L867, these were considered to be cases of progres- 
sive atrophy, which were anomalous in the fad that the lateral columns 
u ere affected. Jaccoud 1 considers the sclerosis as circumscribed or diffused 



Op. cit., p. :;i:». 



LATERAL SCLEROSIS OF THE SPINAL CORD. 293 

Like sclerosis in other regions, the tissue-changes may be observed with 
the naked eye, either invading the white or the gray matter separately, or 

more often together. In this case the lesions are of ancient date. The 
connective tissue is firm and shrunken, and the color of the hardened Bpol 
is gray or pinkish-gray. The meninges may be adherent to the cord if 

the sclerosis be circumferential, but it is more common in uncomplicated 
sclerosis to find no such change. The microscopical appearances are lik<- 
those seen in locomotor ataxia, as the character of the lesion is identical, 
the only point of difference being the location of the tissue-change. Cir- 
cumscribed sclerosis is more rare than the diffused variety, and few cases 
have been observed. Of examples referred to by Jaccoud, in one t la- 
lesion was confined to the lumbar enlargement, and invaded the entire 
anterior columns and a part of the lateral columns; and in another, in 
which the autopsy was made by Frommann, 1 "the sclerosis occupied the 
lumbar segment and the inferior portion of tin; dorsal region. It involved 
in different degrees all the white matter, and the gray was not affected 
except in the gelatinous substance and in the parts of the posterior cor- 
nua which bounded the lateral column." The sclerosis has involved the 
entire antero-lateral columns, the anterior columns alone, or the lateral and 
the lateral and posterior conjointly. In diffused sclerosis, nodules are found 
in various parts of the brain and cord, but the predominance of the sclerosis 
in the antero-lateral column gives prominence to the symptoms which I 
have described. 

Diagnosis. — It is possible that this disease may be confounded with 
either progressive muscular atrophy, lateral sclerosis, or spinal para- 
lysis. In the first we find a train of symptoms consisting of neuralgic 
pains, atrophy of single muscles or groups, and involvement of other 
muscles progressively, and secondary paralysis. There are beside- no 
spasmodic contractions. In lateral sclerosis there is no atrophy beyond 
that resulting from inaction. In the disease known as spinal paralysis 
the lower extremities are generally affected first, and reflex excitability 
and electric irritability are diminished, which is not the case in the die 
which has just been described. 

Prognosis Hopeless. 

Treatment I think it may be said that no treatment offers any 

chance of success, though in the early stages Duchenne claims to ha\ e cured 
Several cases by means of faradization, massage, and other form- of local 
treatment. 

LATERAL SCLEROSIS or THE SPINAL CORD. 

Synonym. — Primary symmetrical lateral Bclerosis. 

Symptoms. — Paralysis of an incomplete character without atrophy, 
and with subsequent contractures, is the marked feature of the malady. 
Like most other diseases of this nature, a Loss ,,t' power i- complained ol 



1 Anatomic des Riickenmarks, Jena. 



294 DISEASES OF THE SPINAL CORD. 

in the beginning. The patient is easily fatigued, and it becomes disagree- 
able tor him to take the least exercise whatever, on account of the wearied 

feeling of the muscles of the leg and thigh which results. The hamstring 
muscles tire the soonest, and it fatigues him excessively to remain for any 
length of time in the erect position. The knees after a while become 
bent, and the lower extremities may grow rigid, while the tendines 
Achillis may perhaps be contracted so that there may be a species of 
talipes. Contractures of the adductors may take place to such a degree 
that the thighs are drawn across each other so that locomotion after a 
while is impossible. Hammond has reported a case of this kind. The 
walk of the patient is decidedly peculiar, as he is unable to lift his feet 
from the ground to any extent, and he consequently stumbles and finds 
great difficulty in progression. Hammond thus describes the gait : " Owing 
to the fact that the patient's extensor muscles are weak, he is unable to 
lift the feet high enough to cause them to clear the ground, and hence he 
throws them out by means of the adductor muscles of the thigh, and thus 
causes them to describe an arc of a circle. Then in putting them down 
the heel -trikes the ground a longer time before the sole than it does in 
the natural gait, and hence the foot comes down with a jerking motion. 
This is t lie ordinary manner of walking practised by a person afflicted 
with the disease under notice. In another form of locomotion the body is 
moved laterally on the thighs, first to one side and then to the other, in 
such a way as to cause the feet to be raised high enough without the com- 
plete action of the extensor muscles. The gait is therefore similar to that 
of a duck, or of a woman with a very wide pelvis. The motion of the 
body is almost serpentine, and the feet glide over the ground barely lifted 
high enough to avoid contact." 1 Sensibility is rarely affected, and reflex 
excitability is as much exaggerated as it is in other forms of sclerosis, for 
instance in locomotor ataxia. The disease runs its course in ten or fifteen 
years, and death is the ordinary result, though several cases have been 
reported as cured. 

Morbid Anatomy The limitation of the sclerosis to the lateral 

columns is nearly always well defined. The sclerosis is symmetrical, and 

Fiff. 44. 




a, A. — Lateral sclerosed patches, (Charoot.) 

Confined to the white matter, bounded in front by the external angles 
of llic anterior horns, and behlB^ by the anterior border of the posterior 

horns. It may extend centstfugally to the circumference of the cord, but 
i~ more often, according t<> Charcot, shut oil' by :i trad of white matter. 



1 l faeasei of the Nervous System, p. 569. 



TETANUS. 295 

Diagnosis. — Locomotor ataxia, lateral amyotrophic sclerosis, and 
spinal meningitis maybe said to be the disorders with which it may pos- 
sibly be confounded. The presence of contractures enables us to dispose 
of the first affection, and the absence of atrophy and bulbar symptoms the 
second. Occasionally the diagnosis will be more difficult, and this is 
when chronic spinal meningitis exists alone, or when the lateral Bclerosis 
is found to be a result of such meningitis, as sometimes happens. 

Treatment Hammond recommends large doses of ergot in the 

early stages. I see no reason why the same remedies spoken of in the 
treatment of locomotor ataxia should not be administered. Conium sug- 
gests itself as a physiological remedy for the relief of the spasmodic con- 
tractions, but, not having used it, I am unable to attest its value. 



TETANUS. 

Synonyms. — Rigor nervosus; Mai de cerf; Tetanos (Fr.); Locked 
jaw. 

Definition. — Tetanus is an affection characterized by tonic spasms of 
a great number of muscles, particularly those of the jaw, neck, back, and 
lower extremities. It is never attended by loss of consciousness, and 
nearly always approaches an unfavorable termination. It is a disease 
which may be either idiopathic or traumatic, and is not confined to any 
age or sex, as it may be a condition at birth (trismus nascentium), or 
occur at any subsequent time. 

Symptoms. — The more familiar examples follow traumatism, and 
such injuries may be exceedingly slight — the wound of a rusty nail, a 
needle, or a blunt instrument being often likely to give rise to the attack ; 
or it may be of distinctly idiopathic origin. The first symptoms generally 
noticed are a stiffness of the neck, a slight soreness of the throat, and a 
contraction of the jaws so that it may be difficult for the patient to open 
his mouth. There may be general malaise and discomfort, which may 
last for several days, and the patient is unable to masticate or swallow his 
food properly, and consequently eats but little. He may think that he 
has simply caught cold, and neglect to seek medical advice; but new 
developments will show the condition to be more serious than he imagines. 

The closure of the jaw may become more complete', and within the next 
twenty-four hours (the fourth or fifth day of the affection) he will show 
unmistakable signs of the increasing violence of the disease. II is face 
wears the peculiar expression which has been called the rtSUS iardontCUS, 
the features appearing pinched and set, and the corners of the mOUth are 
drawn upwards, while the eves are prominent and the hair and 
brows quite bristling. The brows are knit, ami there is a characteristic 
appearance, which, if once seen, cannot be mistaken. Kadclitle considers 

tin- risus sardonicus quite pathognomonic ^\' tetanus. Tain in the epigas- 
trium becomes very severe, and is not relieved by medicine. It is impos- 
sible sometimes to open the jaws even when we desire to give food or 



296 DISEASES OF THE SPINAL CORD. 

medicine, and it is sometimes necessary to use quills and other delicate 
tabes for the purpose of feeding. Spasms of the pharyngeal muscles may 
also defeat all attempts of this kind, for, even if the teeth are parted and 
nourishment is inserted, the food is forced with great violence through the 
nostrils. Other spasms now mark the progress of the disease. The 
muscles of the back begin to be convulsed, and finally those of the 
lower extremities, and as a consequence we observe the appearance of 
opisthotonos, which is an extremely striking symptom, and much more 
common than emprosthoto)ws,wh\c\\ may also take place, or pleurosthotonos. 
It is hardly necessary to say that opisthotonos is the result of a tonic spasm 
of the muscles of the back, so that the patient's body describes an arc, the 
head and heels touching the surface upon which he is lying, and the middle 
of the back being raised some distance therefrom. When the body is bent 
in the opposite direction — forwards — the condition is known as empros- 
thotonos; and when the muscles upon one side of the body are contracted 
we designate the lateral curve produced as pleurosthotonos. During this 
tonic convnlsive state individual muscles may be the seat of painful spasms, 
which are very agonizing. Muscles have been torn across and bones 
broken by the great strain, and the force exerted is something wonderful. 
The tongue is rarely affected, and the hands are not usually at any time 
rigid or contracted. The spasms are easily produced by slight agen- 
cies, a- reflex irritability is decidedly exaggerated. Jarring the bed, 
tickling of the soles, or a draught of air allowed to blow upon the surface 
will immediately bring them on. This convulsive stage lasts until death, 
but when the end is approaching becomes less sthenic as the patient grows 
more and more exhausted. There may be an occasional severe paroxysm 
before death, hut it is not at all like the form of violent convulsion of the 
middle Btages. The pulse throughout the developed disease is very rapid 
and fluttering, and ranges between 120 ami 1 10, and the respiratory move- 
ments are Irregular and catching, as the spasms affect the muscles of the 
thorax as well as others which are directly concerned in this process. 
Dy8pncea 18 very distressing, and is expressed between the seizures by much 
gasping and anxiety of countenance. The skin is dark, and large rings 
about the eyes are indicative of collapse while the face oi* the victim is 

haggard and depressed. The patient perspires quite profusely, and the 
-kin i- excessively hot; and a prominent feature of tetanus is the marked 
elevation of temperature, which rises even sometimes as high as 1 1<» , 

and actually reaches a higher point after death. In a case observed by 

Wunderlich 1 there was a marvellous elevation of this kind, and a very 

tardy fall after death. 

1 Archil der Heilkunde, Bd. ii. ; iii., and v. (1861-68). Reportedbj Radcliffe, 



TETANUS 



297 



Date. 


Respiration. 


Pulse. 


Temperature 
(Fahrenheit). 


24th July, 
25th " 
26th " 

(( u 


18G1 

" 9 A.M. ! 
" G P.M. . 
" 9.20 1*. M. 
" 9.35 P. M. 
after death 

t( n 
H It 
a (( 
(< (( 

a (( 

U (4 
U U 

u u 
u (< 
(< u 
(( (< 

(( u 


death, . 

2; 

5 
20' 
35' 
55' 
GO' 
70' 
90' 
100' 

G hours 

9 " 
12 " 
13^ " 


24 
22 
20 

3 2 

36 


96 
82 

9G 
1 12 
180 


102 

10 4.45 

1 10.1 
1 12.55 








1 12.77 








1 l:; 








1 13.22 








113.55 








1 1 3 . G 7 








1 13.55 








1 13.22 








1 13 








111.8 








106.25 








n>l 








102 








101 











Dr. Joseph Jones, of New Orleans, the author of one of the most able 
articles upon this subject that has ever appeared, has made numerous exami- 
nations of the urine. He found that the quantity of urine excreted during 
the "active stages was greatly diminished from the normal standard, anil 
in the successful cases treated the amount increased with subsidence of the 
symptoms." He also found that the urea was increased during the active 
Stages, and the uric acid was diminished. 

The diminution of the excretion of urine is by him supposed to be 
accounted for by the small quantity of fluids taken, and by the loss of liquid 
in profuse perspiration. 

The mind is perfectly clear throughout the disease, and the patient suf- 
fers great mental misery as he fully realizes his terrible condition : and 
sleep is nearly always absent, this being one of the most distressing fea- 
tures of the disease. If this is obtained, even in brief' snatches, the mus- 
cles are relaxed, and all spasms disappear for the time, bill immediately 
reappear upon awaking. The probable cause of deatli is either the 
closure of (lie glottis, or exhaustion, which is an inevitable result of the 
violent muscular action. In new-born children the disease sometimes 
appears between the first and fifth days, the first Bymptoms noted being 
restlessness, trembling of the lower jaw, ami desire for the breast, which 

the child leaves almost immediately. Al I he end of twenty-four hour-, or 

even earlier, the muscles of the jaw are fell 10 be contracted and rigid, 
ami it cannot open its mouth; there is a peculiarly aged expression 
upon its face, the -kin of the forehead being wrinkled. The eyelids are 

closed, and the lips are compressed oxer the teeth. The head i> drawn 

back, and general spasms of the muscles of the back follow. Period- of 
remission occur, and the patient is thrown into a paroxysm b) ih'' most 



298 



DISEASES OF THE SPINAL CORD. 



trivial agencies. The skin is very red and dark, and after a series of 
paroxysms, which may continue for several days, death closes the scene. 

Causes. — Exposure to damp and cold are the only known exciting 
causes of the idiopathic variety; and traumatisms of certain kinds, or 
accidents during parturition, precede the other form. A punctured wound, 
which may be received from a nail or splinter, is much more likely to 
give rise to tetanus than an incised wound ; and injuries in which there 
is mangling or crushing of muscular tissue are frequently concerned in 
the production of the disease. Railroad injuries are therefore especially 
dangerous. Tetanus sometimes follows surgical operations, and it has been 
thought in these cases to depend upon partial section of some nerve-trunk. 
Dupuytren 1 goes far enough to recommend re-amputation. It may be 
stated that in certain regions there are apparent endemic influences at the 
time of such predisposition, when any surgical operation may have this 
termination. This local influence prevails in Cuba and other tropical 
countries, and in Long Island and in other parts of the American sea- 
board. 

Jones has collected the statistics of tetanus, and the following table 
shows its prevalence in hot climates : — 



Place. 


Period. 


Total deaths. 


Deaths from 
tetanus. 


Proportion. 


London 
Ireland 
New York 
Bombay . 


1850-3-4 
1831-1851 
1819-1834 
1851-1858 


224,515 

I,l87.:i74 
88,788 
42,651 


73 

112 
912 


1 in 3075 
1 in 4987 

1 in 7!s 
1 in 4(j 



I am indebted to Dr. Charles Kindlay, of Havana, Cuba, for the 
following concise table, which shows the prevalence of the disease in that 
island : — 



LeQons Orales, tome ii. pp. o ( J ( J-G 12. 



TETANUS. 



299 





1872. 


1873. 


1874. 


L875. 


1876. 


Average. 






< 


a 


CO 

— 
r 

< 


en 

a 
a 


CO 

— 

- 

-r 
<1 


to 

"3 


2 


CO 

1 


DO 

— 

- 

>d 

< 


a 

a 


CO 

— 

- 

< 


/' 

Cm 

= 




January, 


4 


47 


4 


39 


3 


34 4 


33 


G 


17 


4.2 


34.0 


Pop. of Havana, 
250,000. 


February, 


5 


29 


1 


30 


3 


18 4 


30 


4 


30 


3.4 


27.4 


Births per annum, 
5000. 


March, 


G 


24 


3 


28 


4 


3 1 5 


24 


4 


29 


4.4 


27.2 


Deaths by tetanus in. 


April, 


G 


26 


5 


30 





24 4 


18 


5 


26 


4.0 


24.8 


Adults = 0.192 a year 
per 1000 inhabitants. 


May, 


3 


27 


1 


29 


3 


33 5 


30 


3 


35 


3.0 


30.8 




June, 


2 


24 


3 


33 


2 


3G 5 


29 


5 


39 


3.4 


32.2 


Deaths of infantile 
tetanus. 


July, 


4 


25 


5 


20 


4 


31 3 


36 


3 


35 


3.8 


29.4 


7 j per hundred births. 


August, 


3 


35 


5 


33 5 


45 5 


38 


2 


46 


4.0 


37.4 




September, 


3 


28 


1 


29 


3 


41 3 


4 2 


6 


33 


3.2 


34. G 




October, 


1 


42 


G 


32 


3 


36 1 


43 


4 


3 7 


3.0 


38.0 




November, 


6 


45 


4 


42 


4 


29 3 


37 


6 


41 


4.6 


38.8 




December, 


2 


36 


4 


23 


4 


31 5 


28 


7 


40 


4.3 


31. 6 




12 months, 


4.", 


388 


42 


3G8 


38 


389 47 


388 


55 


408 


48.4 


382.2 


Yearly average. 








4.0 


31.8 


Monthly average. 



Long Island, it seems, has gained an unenviable notoriety as a place 
where tetanus is exceedingly common ; but it will be seen that there is 
much exaggeration in the reports which, as a rule, come to us in the 
newspapers, and which are nearly always sensational. During the past 
year I have devoted some time to the investigation of the subject, have 
written to several well-known physicians of eastern Long Island, and 
have received two or three letters in reply. 

Dr. Stilwell, an old settler of Sag Harbor, whose opportunities for 
research have been quite extensive, writes as follows : "About 2<> years 
ago I came to this place to practise, and learning the fact of the preva- 
lence of tetanus, or its liability from certain accidents, I attempted an in- 
vestigation, but failed of any success or satisfaction. Several Bupposed 
Cases having recovered naturally brought many cases under my observation, 
but most of them died. Several did not, and from my after-remarks here 
you will perceive the reason. I have never known the disease to exis 
an epidemic, but it is apt, at certain seasons of the year, to follow wound-. 
Hot and damp weather, with cool evening-, is it- favorite season.*' The 
Doctor has known but two instances of recovery from traumatic tetanus. 

When a. patient has recovered from tetanus if has been by a very slow 
process, the period between the spasms lengthening until they finally dis- 
appeared. Under favorable circumstances this required several weeks. 
•• I have know n fatal cases of idiopathic tetanus in July ami A.ugus1 caused 
by fatigue and overheating, and sitting down to cool <»tf in the ocean 
breezes. Farmers have often informed me that the white frott on - 



300 DISEASES OF THE SPINAL CORD. 

would give cattle lockjaw. I have known a horse driven to fatigue turned 
out to pasture in a cool night when white frost formed upon the grass, and 
die with tetanus. I have known horses, in the heat of summer driven seven 
miles to the seashore and there cooled otf in the ocean breezes, die of the 
same disease. The multiplicity of eases occur in summer and in the heated 
term with cool nights. A farmer bruised his thumb-nail and pulled tur- 
nips in a frosted field ; he died of tetanus." The other letters I have received 
are in substance very much like that of Dr. Stilwell, and none of them 
suggest that the disease is as frequent as it is generally supposed to be. 
Dr. Benjamin, of Riverhead, says : " I have practised thirty years in this 
village have an average of about one case each year (others claim twice 
that number), and should think the other physicians in the Assembly Dis- 
trict would average about the same; if so, it would make nineteen cases 
each year with a population of 19,000. My opinion is that there has been 
no marked change in the past forty years as to its frequency or fatality. 
A very large proportion of our cases prove fatal in from one to three 
days. Of trismus nascentium I have had six cases during the past thirty 
years, all of which were fatal." The information that I have derived 
from popular sources is, however, somewhat contradictory. I learn that 
about Good Ground, which is nearly twenty miles west of Sag Harbor, 
there are times when traumatic tetanus is very common ; and it is not sate 
for any person who has received even the most trivial injury to remain in 
the neighborhood. 

( apt. Foster and Capt. Joseph Penny, of Ponquogue, which is upon the 
sea-coa-t. state that they have known of tetanus, which was very common 
at certain seasons ; several of their friends have died, and others have 
moved temporarily from the place as soon as injured. It was not uncom- 
mon for women about to be confined to leave the locality; and cases ot 
trismus neonatorum were of quite frequent occurrence. One man whose 
foot had been crushed by a horse died in a few days. 

From .Mr. \Yells, of Quogue, 1 ascertained that the disease is con- 
fined almost eniirelv to the district extending from Moriches to Easl 
Hampton, and that at the extreme easterly end of the Island (Mon- 
tauk Point) no <•;!-<• has been known to occur. So perfect is the immu- 
nity at this place, that colts are taken there to be castrated and not 
removed until the wound is healed. The disease is more common during 
the fall than at any other season. Mr. Wells has known of from twenty 
to twenty-five cases, mostly men and boys, in a district forty miles long, 
during the past ti\<' years. In this region castrated colts generally die 
soon after the operation. In one case, of which my informant know, a 

man WUB shooting ducks in a battery ; his shot-gun accidentally went oil", 

the charge removing about one-half of the great toe. The wound was not 
especially painful, but at the end of eight days convulsions began, and he 
died in thirty-six hours, j 

Mr. White, of South Hampton, scratched his thumb with a brier in the 
field, and afterwards died. Mi - . Hand, of Canoe Place, died after a slight 



TETANUS. 



301 



injury to the ankle. Mr. Wells also told me that several cases followed 
wounds received in the field where a form of shellfish known as the " horse 
shoe" (king crab) is used for manure By the fall these craw-fish have 
undergone advanced decomposition, and their long Bpines, which project 
in any direction, are very apt to wound the bare-footed field band. These 
statements are entitled to some credence, for the Doctor was very often 
not called in. At the eastern end of the island several cases of fatal teta- 
nus within a very short time occurred in the practice of* Dr. Trudeau, then 
of Little Neck. Along the Atlantic sea-hoard I am told that this disease 
is by no means uncommon, and that on the Southern Bea-coasl it is much 
more frequently met with than in higher latitudes. In a very interesting 
communication from Dr. Findlay, of Havana, he mentions a case in which 
the application of a blister in a case of pleurisy was followed by fatal 
tetanus. The accompanying map will enable the reader to perceive the 
geographical distribution of endemic tetanus on Long Island, the dark spots 
showing the limit of the region, and the points where it prevails to the 
greatest extent. 




Map of Suffolk County, Long Island. — 1. Manor. 2. Riverhead. S. Sag Harbor. : 
Hampton. 5. South Hampton. <;. Ponquogue and Good Ground. 7. Quogue. B. West Hampton. 
:*. East Moriches. 10. Centre Moriches. 11. Seatuck. 12. Greenport. 13. Hontauk Point. 14. 
Hridge Hampton. Darkest spots indicate points of greatest prevalence. 

Cold climates have something to do with tin- production of tetann-. as 

we would infer from Dr. Kane's statement that intense old produced "an 

anomalous spasmodic affection allied to leianns." \\ Inch affected m08l of Ins 

party, destroyed two men. and killed all his dogs. Trismus neonatorum 
is supposed by Vogel 1 to depend upon the formation o\ the cicatrix when 

the cord is roughly handled, and there is probably presMire o\' some n.iwe 
1>\ the contraction of the cicatrix. 



1 Diseases of Children, p. 65. Translation bj Raphael, N. V.. 1870. 



302 



DISEASES OF THE SPINAL CORD. 



Frost-bite may sometimes give rise to tetanus, and the following cases 
are examples of this kind: — 

They occurred under the care of Dr. Bethune, of Toronto. The first 
was that of a tanner who was exposed to intense cold for about three 
hours while driving. His feet and fingers became severely frost-bitten 
without his becoming aware of the fact until lie arrived home. On admis- 
sion i" the Toronto General Hospital, four days later, the toes and the 
greater part of both feet were found in a condition of moist gangrene. 

The fingers and parts of both hands on the dorsal surface were black 
and dry. Four days after admission he was seized with tetanic symptoms, 
which rapidly developed. Chloral hydrate in thirty-grain doses, with 
extract of Calabar bean in one-fourth-grain hypodermic doses, until five 
grain- had been given, failed to combat the disease, and the patient died 
in thirty hours after the accession of the attack. 

The second case was that of a man who, having lain out in a barn all 
night, had both feet severely frost-bitten, subsequently becoming partially 
gangrenous. In this case trismus set in nine days after exposure, and 
soon developed into well-marked tetanus, to which the patient succumbed 
in about thirty hours. 1 

Morbid Anatomy and Pathology The older writers have 

written a great deal in regard to the morbid anatomy oi' tetanus, but the 
collected facts throw no light upon the pathology, and are to a great degree 
valueless. 

Lockhart Clarke 2 in 18G5 found in six cases that there was degeneration 
of the gray substance of the cord. " The first case was reported at some 
length, and the lesion was found more or less from the origin of the second 
cervical nerves to the lumbar enlargement. At the second cervical nerve, 
streaks and irregular areas of disintegration were observed in different 
parts of the gray substance, and particularly around the central canal, on 
the right side of which was a space of*considerahle si/e containing a finely 
granular fluid, with the debris of bloodvessels and nerves. The posterior 
and lateral white columns, especially along the edge of the various fissures 
which transmit bloodvessels, were damaged in a similar way, and in some 

sections the deeper portions of the posterior columns which rest upon the 
transverse commissure were softened to a considerable degree. This dis- 
integration was still more marked in the cervical enlargement, chiefly be- 
hind and at the sides of the canal. 'The posterior commissure was wholly 
and the anterior partially destroyed by a, fluid transparent and granular 
area. Throughout tin- cervical enlargement similar lesions were dis- 
covered, varying from ;i state of softening to one of complete solution, and 
diminishing at intervals or almost disappearing, to return shortly in the 

Bame form. At the upper part of the dorsal region the shape of the cord 
\\;i- much altered, and extensive lesions of the Bame kind were everywhere 
-e. ii. In both lateral halvesj*!' the gray Substance, the left lateral col- 
umn-, the right antero-latejal column, the superficial portion of tin- ante- 



1 London Lancet, March, L875. 

■ Med.-Chir. Tran ■.. L 848 and 1865, and Bled. Times and Gazette, L865. 



TETANUS. 303 

rior columns, and in the posterior columns, similar appearances were 
found. Below this point there was Less disease as far as the fourth dorsal 
vertebra. Here, in addition to the area- of disintegration, large extrava- 
sations of blood were found along the whole lateral pari of the gray -lib- 
stance on both sides of some sections, in one Bide only of others; while the 
lumbar region manifested the same lesions as the cervical." 

Dr. James Tyson 1 lias detailed two eases in which softening of the pos- 
terior columns occurred. In one of these there was extravasation of blood 
in the posterior columns, and to some extent from the vessels of the pia 
mater. The central gray commissure was destroyed. In ilie other case 
no extravasation was found in the posterior columns, but there was venous 
congestion of the dura mater. I was presented by Prof. L. McLane 
Tiffany, of Baltimore, with a piece of the cord of one of his patients who 
had died with tetanus following a severe burn. The pia mater was greatly 
thickened, and the small posterior arteries were enlarged. Throughout 
the section, which was viewed at first with a low power objective. I per- 
ceived a rather extensive increase of the neuroglia. The anterior n< 
roots appeared to be very well defined. Throughout the white and gray 
matter there were visible numerous round cells quite translucent and 
bright, which resembled somewhat colloid bodies. These were more 
plentiful in the posterior column. The vessels of the gray matter were all 
more or less enlarged, and some of them were surrounded by spaces which 
were considerably wider than the diameter of the vessel. The cells of the 
anterior cornua were quite disintegrated, and some had taken an oval form. 
Those that could be recognized were found to have broken processes, and 
many had granular contents. The nerve-trunks were unaffected. 

Arlong 2 and Tripier, Erichsen, and Bouillaud found that the end of 
the nerve in the wound was diseased, and Lepelletiei 3 and Froricp 4 dis- 
covered in one case that the neurilemma of the nerves in the vicinity was 
the seat of inflammatory changes, which extended from the periphery to 
the cord. Tins latter appearance indicates an exceptional condition of 
affairs, and as for the nerve-change in the wound, it is not to be won- 
dered at. for if there is any importance to be attached to the circumstance 
of the morbid appearance of an injured nerve, it is certainly inconsidera- 
ble, when we consider how frequent must be such a pathological condition, 
and -till there is not a proportionate amount of tetanus. 

Our knowledge of the pathology of tetanus 18 based almost entirely upon 
the experiments of physiologists, and we are left somewhat in the dark as 
to the questions: 1. Whether it is a central disease resulting from a mor- 
bid peripheral irritation which is reflected upon the cord. "J. Whether it 
is a central disease per se, and the appearances noted after death art' pri- 
mary. ;!. Whether the morbid changes are secondary to the symptoms, 

and due to mechanical can-' 

We have bo far been taught how general spasm may be produced. 

1 The Practitioner, Aug. i>77. chives de Physiol., 1870, 

3 Revue Medicale, U.. . ' Neue NotUen, L8 



304 DISEASES OF THE SPINAL CORD. 

Mitchell 1 and Morehouse caused in animals very violent convulsions 
l»v injecting into the vertebral canal a halt* ounce of fluid, and very hot or 
\ cry cold water seemed to aggravate the spasms. Cold applied to the 
spine, whether produced by the rhigoline spray or by ice, gave rise to 
the same phenomena. Cold to the medulla caused the animal to topple 
backwards. 

Upon examination the vessels were found to be intensely congested. 
So far, we are furnished with the first link in our chain. Assuming that 
the spasmodic movements are due to a congestion of the cord, and con- 
ceding that pathological anatomy has furnished us in nearly every instance 
with evidence of congestion of the gray matter, we are to discover what 
i- ili<- factor of such congestion. It may depend upon a reflected im- 
pression transmitted to the vaso-dilators, or it may depend upon local 
irritation by impure blood which produces secondary hyperaemia. In 
strychnine poisoning, the symptoms of which resemble those of tetanus 
very closely, the spasmodic phenomena are undoubtedly due to the im- 
perfect oxygenation of the blood ; consequently the cord is supplied with 
blood loaded witli carbonic oxide. It seems to me very possible that 
the same condition of affairs exists in tetanus ; that there may be direct 
irritation of the nervous matter of the cord dependent upon some primary 
blood condition. 

Fox 2 very clearly expresses himself as follows: "The abnormal blood 
imperfectly nourishes the cord. An imperfectly nourished cord is ipso 
facto an excitable, an impressible cord; this impressibility renders arterial 
spasms abnormally facile, whether the exciting cause is the circulation in 
the cord of more of the morbid blood, or reflected irritation from a diseased 
nerve at the periphery, or reflex irritation from any other cause and from 
any other point in the body, and if this arterial contraction goes on for 
any protracted period, or is frequently repeated, we may find various 
Lesions due to imperfect blood-supply in addition to those due to dimin- 
ished nutrition from the original nature of the blood, while, as a sequence 
of the BpasmodlC arterial contractions, Ave get hyperaemia and perhaps 
exudation, and lastly the pressure of the exudation or some peculiarity 
in its nature may lead to some disintegration of the nervous centres," 

This theory seems to me to be tenable tor several reasons: 1. Injuries 

of peripheral nerves are common, and the cases of resulting tetanus are out 

of all proportion to those presenting no subsequent nervous symptoms. 2. 

li- endemic nature, its prevalence in certain districts, and its not uncom- 
mon idiopathic origin when there is no ascertained eccentric cause. 3. 

The appearances of the cord arc of a destructive character, and it is a 

matter of doubt whether they are not more a result than a cause. 

Considerable discussion has taken place in regard to the cause of the 
high elevation of temperature. Yerneiiil does not consider it due either to 

myelitis of the Buperior part of the cord, or to asphyxia or muscular con- 

1 Alii. JoUin. Med. Science-, L866. 2 Op cit., p. 862. 



TETANUS. 

tractions; but Muron is decidedly of the opinion thai Buch increase in 
temperature is alone the result of muscular action. Mason has experi- 
mented, and found that the temperature of a tetanized muscle is often 
increased from one to two degrees. 

The medulla has been found in more than one instance to be the seal of 
grave lesions, and it is probable thai the trismus and other evidences of 
an excited state of cranial nerve innervation, which occur in the begin- 
ning, are indication- of primary disturbances in the bulb. 

Diagnosis. The diseases with which tetanus may be confounded are 

hydrophobia, strychnine poisoning ^ hysteria^ and acute sptned meningitis. 
In the first there is no risus sardonicus; the convulsions are clonic; there 
is the noisy hawking and effort to spit; the dread of water, the delirium, 
and finally the history of a bite by a rabid animal, which, however, is not 
always to be ascertained. Strychnine poisoning is very easily mistaken 
for tetanus. In poisoning by a large dose of the alkaloid the symptoms 
appear rapidly, and death takes place in a short time. The hands 
arc clenched and rigid, but the jaw can be opened, which is not possible 
in tetanus. This resemblance between the two condition- has been made 
use of in more than one poisoning case as a -round of defence, and in that 
of Cooke, who was poisOned by Palmer, the question was narrowed down 
to the appearance of the cord. Cases of hysteria sometimes present symp- 
toms which not rarely counterfeit those of tetanus. The jaw may be 
locked, hut there will he few of the other features. Hysterical patients 
are nearly always seemingly unconscious, and there are no evidences of 
Buffering whatever. In spinal meningitis the muscular rigidity seems t<> 
he dependent, in a great measure, upon the patient'- efforts to relieve the 
pain which is produced by an uncomfortable position. The locked jaw. 
which i> an early symptom of tetanus, is absent in acute spinal meningitis. 

Prognosis. Dr. done.- 1 lias collected 180 case- «»f tetanus, 213 of 

which recovered under treatment, the mortality being 19.2 per cent., or 
one death in 2.02. These were all cases of traumatic tetanus. The per- 
centage of death in the British army during the Crimean War was 91 per 
cent. ; and Baron Larrey's estimate of mortality of the French army under 
Napoleon was at about the same rate. 

In regard to the time of death Dr. done- found that of ."<<> cases, in which 
the disease followed slight injury of the extremities, 13 proved fatal in a 
Bhort time, and of the whole number of deaths reported 2 1.1 I per cent, ran 
a rapid course after slight injuries, and terminated in death in a few 

One case died on the second day. Cases are reported which have termi- 
nated fatally in twenty-four hours after the appearance of Bymptoms. In 
one case, mentioned l>\ Dazelle, they appeared on the third day, ami the 
patient died tie- same night. Hammond lays stress upon the statement 
that the prognosis is governed by the interval that elapses between the 

receipt of the wound and the appearance of the Bymptoms, ami that the 

longer this interval i- the more favorable are the patient's chances. Man\ 



1 Medical and Surgical Memoirs, vol, i.. New Orleans, I s :.;. 

i>0 



306 DISEASES OF THE SPINAL CORD. 

writers agree that elevated temperature plavs an important part in the 
prognosis, and that any increase is to be looked upon with alarm. The 
duration of the attack is to be taken into account, and every day bridged 
ov.-r by the patient after the fourth or fifth increases his chances of 
recovery. CM" course the gravity of the affection depends much upon the 
violence of the paroxysms. 

Treatment — It would be useless to discuss the merits of the many 
drugs that have been brought forward from time to time. Our most effi- 
cacious remedial agents are the depresso-motors. and among these may be 
mentioned chloroform, chloral hydrate, Indian hemp. Calabar bean, and 
conium (FF. 56, 39, 3, 1. 82, oi). 

Calabar bean, which has enjoyed a deserved popularity, has been made 
if with great success by Eilert, Holhouse, Wood, Watson, and a. host 
of others. Holhouse in 18G4 reported two cases, one of which was cured 
after having taken 3-4| grains of the extract every two hours. Ashdown was 
not so successful, ami Spencer and Dickenson had the same discouraging 
experience. Even Watson was one of the first to use the remedy, and 
three out of his four cases of tetanus were cured by the administration of 
ten drops of the tincture every hour, and by a subsequent increase in the 
dose. The drug may be given in full doses, say from one-quarter to one- 
third of a grain of the extract every two hours. 

The chloral treatment has certainly been more efficacious. Surgeon- 
Major Hunter 1 reported two cases : one a boy, and the other a man of 40. 
In the first case chloral was combined with cannabis indica. R. Tr. 
Cannabis ind. ni^x; potass, bi-omid.gr. v, every third morning; and chloral 
hydrat. gr. xij, three times a day. together with inhalations of chloroform 
as required. The other patient took 20 grains of the chloral thrice 
daily. Opium and chloral in combination have perhaps been more effec- 
tive than the chloral alone, and Pelsal* saved three cases out of four by 

this treatment. II. C. Wood reports 9 cures out of I* cases by chloral. 

Chloroform has not proved to be the valuable remedy that many have 
supposed it t<> be, and it has only the power to "crowd down the bad 
Bymptoms which burst forth usually with additional fury when the narcosis 
subsides." 

Aconite has been of service upon many occasions. It was first u^-d bv 

Paee" in a case of traumatic tetanus. The toxic effects of the drug were 

produced, ami during their continuance there was a remission of svmp- 
toms. The patient was first reduced to a condition bordering OH syncope, 
ami afterwards stimulated. I)e Morgan and others cured tetanus with 
thifl remedy, and it> place in the therapeutics of the affection is b\ no 
mean- an Inferior one. 

The pulse 18 markedly lowered, the muscular rigidity relaxed, and a 
condition of akincsis and prostration lake- the place of the irritable ner- 



1 radian Med. Gaz., Feb. i. is;:,. 
1 Quoted in Practitioner, August, 1871 
1 Lancet, April i. is L6. 



TETANUS, 



107 



vous state. Curare, nitrite of amyl, and belladonna, as well as a hosl of 
remedies of the same character, have been praised from time to time, 
but most of them are useless. Chloral hydrate, either in combination 
with aconite, or chloroform, and cold to the spine, which may be ap- 
plied by the ether spray as recommended by Carpenter, I think i- the 
best form of treatment, and should be resorted to as early as possible. If 
these remedies fail, Calabar bean, curare, or nitrite of amy] may be tried, 
and conium, which is a. powerful depressor of spinal excitability, may he 
given a trial. Warm baths have been recommended. 

" Dr. F. Franzolini 1 relates a case of tetanus arising from exposure by 
sleeping on the damp ground after great fatigue successfully treated by 

prolonged warm baths and the continual use of chloral and morphia. Tic 
chloral was given frequently by the stomach, and the morphia by subcuta- 
neous injection. The first bath was for six hours, at a temperature of U) c 
C. (104: F.), and subsequent ones lasted five, four, three, or two hours. 
This treatment was carried out from the 18th to the 30th of the month; 
but the daily use of chloral and morphia was continued some time longer. 
Of the first ninety hours of his disease, the patient passed forty-eight in 
tin- bath at 10° C. In twenty-nine days he consumed nearly four ounces 
of chloral hydrate, and about twenty-two grains of hydrochlorate of mor- 
phia were injected. Although kept so long in a state of almost constant 
narcotism, the mental powers of the patient were in no way affected." 

H. de Renzi, 2 of Genoa, has spoken highly of the dark-room treatment. 
His patient was kept absolutely quiet. He ascribes the succes- to the 
belief that the absorption of oxygen and elimination of carbonic oxide are 
impeded by darkness. 

The other indications seemed to be perfect quiet, and during and after 
the attack ample nourishment. Niemeyer 8 believes in clysters containing 
twenty or thirty drops of laudanum. He also recommends chamomile baths 
in the infantile variety. 



1 The Doctor, Oct. 1, 1875. Abs. in Phila 

2 (ia/. Med. de Paris, Xo. 32, 1877. 

3 Text-Book of Pract. Med., vol. ii. p. 352 



Med. Times. ( >ct. SO, 1875. 



30S BULBAR DISEASES. 



CHAPTER XII. 

BULBAR DISEASES. 

EPILEPSY. 

Ssrnonyms— L'Epilq^ie (Fr.); Fallsucht(Ger.); Mai caduco (Ital.). 

Definition. — This most familiar of all nervous diseases is characterized 
by loss of consciousness of variable duration, attended or unattended by 
either slight muscular spasms or general convulsions. 

The relation of these two elements, the psychical and physical, is not 
always tlie same, as in some forms of the disease there is a momentary loss 
of consciousness and perhaps no appreciable spasm, or the two may coexist. 
there being protracted loss of consciousness and violent convulsions. 
There are sometimes very peculiar combinations of symptoms which will 
receive mention hereafter. 

The scope of this work does not permit me to consider the history of the 
disease; suffice it to say thai its antiquity dates back to the days of Hip- 
pocrates and Aretaus. and biblical references to its existence are common. 

Cooke 1 thus speaks of the early writings: "Epilepsy has been distin- 
guished by a great variety of names such as morbus sacer, comitialis her- 
culens. caducus, etc. A ret a mi- say S, it may have been called sacred on 
account of the magnitude of the evil, it being customary to call what is 
greal by that name : or because it is to be cured rather by the Divine than 
by human power, or because persons laboring under it have been thought 
possessed by demons. 8 ..... Some of the ancients were of 
(.pinion that epilepsy Mas denominated the Herculean disease because 
Hercules was Bubjecl to it ; but Galen says it was so called on account of 
its form or magnitude." 

" Epilepsy was denominated morbus comitialis, either because it fre- 
quently occurred in the crowded assemblies of the Romans called comitia, 

in which the passions of the people were often much excited, by which it 

mighl be occasioned^ or because it was customary to dissolve the comitia 
if during the sitting any person should be affected by it. 

"The application of the term caducus, a falling sickness, is too evident to 
need illustration." 

In our description of the affection it is impossible to make any well- 
defined division; suffice it to sa\ thai all wrritera recognize forms known 
as Haul mat or Epilepsia gravter^ and Petit mat or Epilepsia mitior, 
LV\ nolds dn idea the latter info two varieties, \ iz. : l-t. A form with e\ i- 



1 Treatise on Nervous Diseases, Am. ed. 1824, p. S26. 
i Am. de Caus. <•< 8i«m. Morb., lib. i. «•. i. 



EPILEPSY. 



309 



dent spasm*, and another without evident spasms. Besides these, various 
irregular forms have been included, such as masked epilepsy and hystero- 

epilepsy. 



THE GRAVE ATTACK. 



Symptoms. — The most familial- varietyis known as Epilepsia gravior, 
and it maybe described as an attack expressed in four stages: 1st A 
premonitory stage; 2d. Stage of convulsion; 3d. Stage of subsidence; 
and 4th. A stage of stupor, or " after-stage" (Reynolds). The firs! 
may often be absent, for in many cases there is a sudden de'int ; but if 
such be not the case, the patient, may have well recognized warnings wliirh 
may be cither psychical (mental or emotional), [notorial, sensorial, or 
vascular, these latter being objective indications. Though these warnings 
are sj>oken of by many patients, it is almost impossible to rely upon their 
testimony, a- the demoralization dependent upon the anticipation of the 
attack, or the short duration of such premonitory symptoms, is sufficient to 
prevent them from analyzing their feelings. It is, however. i*»-il>le in 
many instances to collect information from a number of cases which shall 
be a basis for the general classification of premonitory symptoms. 

Very often the attack will be immediately preceded by a vague dread. 
or an undefined fear of some impending trouble. 

In one of my cases — a remarkably clever and intelligent young lady — 
there is a condition of exhilaration of spirits, and a mental activity which 
lasts for some hours. Although deeply under the influence of the bromide, 
she will come out of her apathetic state and chat with her friends upon all 
subjects in the most entertaining manner. Twitching of the eyelids or of 
the lower extremities, vertigo with rotatory movement, and tremor are 
examples of the disorders of motility which occasionally precede the 
attack. Sometimes there is an elevated sensitiveness of the organs of 
special sense. 

Hallucinations of hearing, or visual hallucinations, are not uncommon. 
One of my patients has often seen a fiery cross; and another refers i<> a 
locomotive with a glaring headlight, which rushes upon him ; while a 
third hears voices; and in two cases the patients say that they "smell 
smoke." Morbid sensations, which cannot be defined, are spoken of oc- 
casionally, and a vague sense of weight in the epigastrium, head, or some 
other pari of the body is a frequent precursor of the attack. Occasionally 
the peculiar sensations begin at some remote part o\' the body, and seem 
to move rapidly towards tie' head; Buch phenomena are known a- aurce. 
These aurce have been compared to the blow ingot' wind over the surface, 
the creeping of insects upon (lie skin, or the pricking of needles. They 
lasl but for a few seconds, and are sometimes perceived, but not always. 
In the wards under my charge at the Epileptic Hospital, the patients 
sometimes have perceived the aura in time to seek the nurse or to attract 

the notice of the other patients. Careful investigation o\' twenty-nine 

cases resulted in the discovery that eighteen of them had a warning of 



310 BULBAR DISEASES. 

some kind, four had none, and the rest gave us unsatisfactory ansAvors. 
After a long process of condensation of statements, I find that seven had 
an aura starting from the epigastric region, two complained of constriction 
of the chest, seven had slight vertigo, and one had an aura starting 
from the extremities, and in one there was trembling of the right hand. 
Headache preceded the attack in four, and the "indescribable feeling" of 
the coming tit was alluded to by a. number. In one remarkable case the 
first intimation of the attack was the violent jerking of the head to one 
Bide, and ;i species of vertigo. In another case the patient muttered in- 
coherently for a full minute before the actual attack. A third case was 
equally curious. The patient, whose mental condition was good, would, 
without any apparent reason, attract the attention of persons about him by 
the repetition of the syllables " be-lub-be-lub, be-lub, lub, lub-a-lub, a-lub," 
pitching his voice in a high key, and gradually lowering the tone until the 
last part of his utterance was hushed and low, and then, after giving vent 
to ;i species of groan, he would become convulsed. Trousseau 1 calls at- 
tention to the " vascular prodromata." A local determination of blood 
may occur in the linger, for instance, causing it to swell, reddening the 
skin, and rendering it successively, within a very short time, red, and of 
a more or less deep violet color; or, again, the skin may become exces- 
sively pale after having been injected for some time. The swelling is 
real, not apparent ; for rings previously easy suddenly become too tight 
for tin' linger. The only premonitory symptom may sometimes be an 
involuntary discharge of urine. It is difficult to distinguish this accident, 
however, and it is Very liable to be considered a part of the attack, which 
it may be in reality. 

•><l Stage {Stage of Convulsion) In many cases the first indication of 

the attack is a wild cry, which startles those about the patient. I 
have Been ;i Boldier marching in procession throw up his gun and shriek 
so loud a- I-* be heard half a block away, and fall to the pavement in a 
convulsion. This shriek is a psychical manifestation, and different from 
another form of cry which the patient may utter. This second variety is 
less noisy, and is produced by the forcible expulsion of air through the vocal 
cords which follows spasm of the thoracic muscles. It is more a species 
of groan. Simultaneously there is loss of consciousness, and the patient 
falls to the ground, and i- agitated by ionic contraction of all the muscles 
of the body, but usually those of one side more than the other; so that his 
body is twisted and bent. The muscles of the neck are strongly con- 
tracted, while the face is generally distorted. The stronger contraction 

,1' some muscles than others draws the weaker side so that movements are 
produced which are not the result of clonic contraction, hut rather an evi- 
dence of unequally expended forces." Respiration stops, or there may be 
;i long expiration, and then Btopgage altogether for a few seoonds. The 
pulse is now rapid and eery^nall, :i result, probably, of compression of 
the arteries bi muscular masses, and the heart-beats are strong. At the 



Clinical Medicine, Am. ed., v.. I. i. p. ;;,. 2 Reynolds. 



EPILEPSY. 311 

end of a few second?, and rarely after a minute, the convulsions become 
clonic, the patient throwing his arms about violently, or bumping tlie back 

of his head upon the floor, lie is still unconscious, and may have evacua- 
tions from his bowels and bladder, or, as in some of the cases thai I have 
seen, there may be an emission of s< men. Reynolds calls attention to vom- 
iting, a symptom which I have several times witnessed. The respiration 

now becomes labored and rapid, and there may be snoring. Froth col- 
lects about the mouth, which may be tinged with blood, as the patient 
sometimes bites his tongue or lips. The surface, which was in the first 
stage quite pale and cool, now becomes dusky, and of a dark livid color. 
The pupils may remain dilated as they were at the onset of the attack, or 
may be unequal. From my note-book I find that the following points 
were observed in the twenty-nine cases previously alluded to. In twenty- 
six the convulsions were quite general. In three the legs were more con- 
vulsed than any other part. In three the arms were especially agitated. 
In one patient the movements were confined to the left side. The cry 
was very piercing in five instances. In three there was only a moan or 
gurgling expiratory sound. Twenty-four of these patients bit their 
tongues. In twenty-three the pupils were widely dilated. In two the 
dilation was not so marked. In four no appreciable difference was no- 
ticed. After the stage of tonic convulsion, which lasts a few minutes, the 
third stage is reached. 

3d Stage (Stage of Subsidence) — This is marked by a gradual re- 
turn of consciousness. The patient may stupidly turn his head or look 
upwards, the eyes having a meaningless expression, and the balls oscillat- 
ing slightly. He may strive to express himself, but only gives utterance 
to a series of unintelligible sounds. He may make some effort to rise, 
but finds it impossible to do so. His pulse is small and thready, or some- 
times full and bounding, especially when the first two stages have been 
short. His eyes are injected, and his pupils either normal or contracted. 

±tli Stage (Stage of Stuj>or) Exhausted by his attack, he falls into 

a Bound sleep, which is so profound that he lies where he has fallen, and 
resents any attempt to remove him. The stupor may be so deep, 
however, as to make him unmindful of what is going on about him. His 
sleep lasts for several hours, and is characterized by snoring. W the 
patient recovers without the stupor, he is very irritable and cross. II' 
complains of headache, or perhaps nausea, and vomits; and his pulse is 
irritable and irregular. Thompson 1 calls attention to the tracings ob- 
tained in epilepsy when the heart is healthy, and it is possible to obtain 
good results. He as well as Lorain found that the sphymograpb tracing 
exhibited a distinct dicrotic notch. 

In regard to the time of at tack, two divisions have been made — noctur- 
nal and diurnal. I have thought it best to make another, \ iz. : ma- 
tutinal. 

Perhaps nocturnal epilepsy is much more common than the other forms, 



1 AYest Hiding Reports, vol. ii. p. ;'.",;. 



312 BULBAR DISEASES. 

for a great many patients never have attacks at any other time, while some 
may have them at all times, and a few only (luring the day. A large number 
arc attacked just as they awaken ; and I have met this form so frequently 
that I prefer to use the term matutinal for the attacks occurring 
between five and nine in the morning. The only sign of a nocturnal 
attack may be the evidence of involuntary passages of urine and feces, 
and sometimes both. Blood upon the bed linen as a consequence of 
tongue-biting i^ another indication, and the trouble which is required to 
rouse the patient is a third. Of forty-eight patients, fourteen had their 
attack- at irregular hours, seventeen had their attacks at night only, live 
in the day, and twelve in the morning. 

Dr. Maury, of Memphis, has communicated to me the following two 
cases of dislocation of the bones during an epileptic paroxysm. This is a 
rare accident in epilepsy, although it is more common in tetanus. 

( lse I. A man from Holly Springs, Miss., was sent to Dr. M. in Dec. 
1876. The patient was sixty years of age, a planter, and of good habits. 
About one year before, after eating his supper, he became ill and had 
convulsions. In the night he had fresh convulsions, and suffered consid- 
erably from pain in the right shoulder. The convulsions recurred at in- 
tervals of ten days. When he was brought to Dr. M. the shoulder was 
found to be shrunken, and the humerus dislocated and immovable. 

Case II. A lady from Alabama, during the menopause, was affected 
with epilepsy about two years and a half before the Doctor saw her. 
She was attacked at night with convulsions and pain in left hip. These 
attack- occurred at intervals of from two to four weeks before she was 
seen l»v a physician. Left lower extremity found to be shortened about 
two inches, femur evidently dislocated. Muscular contraction on outside 
of leg; toes exerted, and thigh turned inwards. In this case no attempt 
was made to reduce the dislocation. Whenever she had convulsions there 
\\a> pain in region of liver. 

THE LIGHT ATTACK. 

Symptoms. — The lighter forms of epilepsy are included under the 

head of Epilepsia mitior^ and are attended by a very transitory loss of 
Consciousness. There may he little or absolutely no spasm, and the attack 
may hi- BO linpronounced as to escape the notice of those persons who may 
happen to be present. The patient may be eating at the time, and suddenly 
drops his knife and fork ; or he may be engaged in some occupation, and 
suspends operations for a, second. In one of my patients the only indica- 
tion of the attack was the rolling upwards of I he eyes. Another, a gentle- 

ni:iii. when writing would Btop for a moment and go on with his work 
entirely unconscious of any interruption. If walking, there may he a 
sudden loss of equilibrium, bul he rarely falls. The face may he blanched 
or flushed momentarily, and the patient may suffer no bodily discomfort, 
bin i- sometimes restless, depressed, or Low-spirited, 

A more aggravated Btate may exist, in which the muscular Bpasms are 
more marked. 

The attacks, which have been described as " weak spells," or "fainting 






EPILEPSY. 313 

fits," by uninformed people, consist in more protracted loss of conscious- 
ness, accompanied perhaps by strong muscular contractions of the muscles 

of the face or arms, pallor, and dilatation of the pupils. I have a patient 

under observation who has a distinct epigastric aura; she then becomes 
rigid, holds her breath, grasps the arms of her chair; her bead 18 drawn 
forwards, and so she remains for a minute or two. 

The foregoing forms may coexist, there being distinct attacks of grand 
mal, with repeated petit mal seizures, which seem to have no special rela- 
tion to the more serious convulsions. Twelve of the twenty-nine cases 
suffered from grand mal alone, and seventeen had both forms, and in these 
cases the petit mal predominated. 

As to periodicity and frequency of the attacks there is much to be said. 
There is a peculiarity in the regularity of the seizures which is to be 
observed in very many cases. A tendency to weekly, semi-monthly, or 
monthly recurrence is noticed. 

When the fits take place there may be only one at a time, or there may 
be a number within twenty-four hours or two or three days, and then an 
interval of the duration I have just described elapses before a fresh attack 
or series of attacks takes place. 

In Reynolds's experience there are four times as many epileptics who 
have their attacks more frequently than once a month as there are who 
have them at long intervals; but I am disinclined to agree with him 
" that males are more subject to monthly attacks than females, and that 
attacks in the latter are not as a rule monthly seizures." 

I discover every day numerous verifications of the menstrual influence. 
In forty patients I find that eighteen occur during or just after the days 
the woman has her catamenia ; and in one case much interest arises from 
the fact that there was dysmenorrhoea, and that when this was relieved 
the attacks disappeared. 

In many chronic cases, especially when there are complication-, there 
is rarely any regularity in the appearance of the attacks. In the Epileptic 
Hospital, on Blackwell's Island, I find extreme variation in their number; 
and there are patients under treatment who have had but three or four 
attacks in one year, while there are others who generally have front five 
to thirty each week ; but this great frequency is exceptional. The attacks 
of petit null are much more numerous, but from their very transitory cha- 
racter it is difficult to make any estimate which is at all useful. The 
irregular forms of the disease are of greater interest as curiosities than 
anything else, but derive some importance from their medico-legal bearing. 

[RRKGULAR ATI' \< KS. 

There may be a form known as aborted epilepsy, which consists in the 
expression of all the features of ordinary haut umL wit hoi it complete 1"— of 
consciousness. The attacks maj occur in the course of ordinary epilepsy. 

The most peculiar example- of irregular M'i/.urcs are described DJ halret. 



314 BULBAR DISEASES. 

Hughlings Jackson, and others. While in this state the patient will do 
the most eccentric things imaginable, the mind being apparently in a con- 
dition of vacuity, and the individual becomes more an automaton than a 
human being. 

Mcsnet, of the St. Antoine Hospital, came across a very interesting ease. 
which he describes in the Gazette Hefydomadaire, July 17, 1874. The 
patient has been known as the " Automatic Man," and his history is as 
follows : — 

•• A young man during the late Avar had a portion of the left parietal bone, 
about eight centimetres in extent, carried away by a ball. Hemiplegia of 
the right side was the consequence, but this gradually disappeared. For 

some time past he has been the subject of attacks, lasting from twenty- 
tour to forty-eight hours, attended by very extraordinary phenomena. 
During these he seems to act exactly like an automaton, walking continu- 
ously, incessantly moving his jaw, knitting his brow, and appearing abso- 
lutely insensible to all that surrounds him. Not uttering a word, he walks 
straight forward, and when he meets with an obstacle, slops short, explores 
it with his hand, and tries to pass on one side of it. Surrounded by a 
circle of persons, he stops at each, and endeavors to pass by the intervals 
formed by their joined hands, then turns back, comes in contact with the 
next person, and resumes his round. All this time he never manifests 
th<' slightest consciousness, just as if be were in a state of somnambulism. 
I b- is absolutely insensible to pain, so that pins may be thrust through the 
cheek or into the fingers, or very powerful electrical shocks maybe admin- 
istered without the slightest sensibility being manifested. What, however, 
i- very remarkable, is that by bringing him in relation with certain objects 
we are enabled to determine in him the entire series of acts which are Cor- 
relative with the sensation thus aroused. Thus, if a. pen be placed in his 
hand, he seeks for ink and paper, and writes a letter in a very good hand, 
in which he speaks very sensibly about different matters which concern 
him. If a leaf of cigarette paper is plqced in his hand, he feels in his 
pockd for the tobacco, rolls up the cigarette \ cry adroitly, and, having 
found his match-box, lights it. If the match be extinguished just a- it 
reaches the cigarette, he finds another, and that several times, until he is 
allowed to light hi- cigarette. II' at the moment when the match is ex- 
tinguished, another already Lighted is presented to him in its place, it is 
impossible to induce him to light the Cigarette by means of the substituted 

match. He allows his moustaches to become burned without, offering any 
resistance, but he will not employ the light thus presented to him. If 
chopped charpie be placed in his pocket instead of his tobacco, he makes 

the cigarette with this, ami Lights and smokes it without seeming to pay 
any attention to what he is Bmoking. 

\mong the various experiments devised by \)v. Mesnet, there is one 
which is particularly curious. The young man is ;i singer at concert- bj 

profession, and if gloves he placed in his tiands he immediately puts them 

on. and searches lor paper. When a roll of this, resembling music in form, 
i- given to him, be places himself in the proper position ami begins to sing. 
Il would -e. in. in fact, thai l.iy.lile sensation induced in him becomes the 

point of departure, and as if of escape, of a series of acts correlative to this 
initial sensation— acts which he accomplishes automatically, without Letting 
them deviate front their habitual and regular succession. Lastly, it is to 
be noted that, while in this singular condition, the patient steals all that 



EPILEPSY. 315 

comes within his grasp. If he touches any person, he feels for his watch- 
pocket, and invariably detaches the watch and puts it in his own pocket, 
whence it may be immediately removed without his making the slightest 
opposition. The crisis once over, he lias no recollection whatever of what 
he has been doing, and becomes again perfectly reasonable." 1 

An irregular form of the disease is known as " masked epilepsy." The 
patient in this state may not fall to the ground, but while in a state of un- 
consciousness will evince a great deal of muscular activity. An epileptic 
in my ward is in the habit of tearing through the hall, colliding with such 
patients as may happen to be in her way, and finally recovering conscious- 
ness, when she has no recollection of her attack. I have noticed the same 
phenomena in other cases. 

Another form is connected with the commission of purposeless acts. 
Hammond reports the case of a gentleman who disappeared and travelled 
about the country for some days, and when found could not give the 
slightest history of his whereabouts. The individual, in reality, lead- a 
double life, and while the automatic state prevails lie may commit deeds 
of violence which may subsequently cause him a great deal of trouble ; 
and in such cases only, the history of undoubted epilepsy should alone be 
sufficient to exonerate him. I believe it is strongly improbable that there 
is ever an attack of masked or aborted epilepsy without expression of some 
of the evidences of the true paroxysm. / 

The sequences - of epilepsy are various, but it does not necessarily 
follow that any mental impairment should result. It is true that in 
some cases such a termination is possible. Idiocy and epilepsy some- 
times go together, but it must be remembered that the former is a con- 
genital state. Examples of general mental failure are by no means rare, 
and in some cases the disease slowly undermines the patient's intellectual 
condition. An apathetic state is the primary result. Any one who has 
seen one of these old cases (especially if the patient be the victim of petit 
med), with dull fishy expression of the eyes, a. leaden, sallow countenance, 
a full lip with imperfectly defined vermilion border, sluggish cutaneous 
circulation, loss of memory and dulness of wits, will recognize the condi- 
tion I have endeavored to describe. An epileptic convulsion in infancy 
may give rise to cerebral hemorrhage from a vessel ruptured during the 
paroxysm, but the accident is almost unheard of in adult life. 

Epileptic mania, which Reynolds considers to occur in about one-tenth 
of all the cases, is not confined to any particular time. It may occur be- 
fore the attacks, or, as is more often the case, succeed them. In this con- 
dition epileptics may he occasionally very dangerous, and give way to 
outbursts of violence, for which, of course, they are entirely irresponsible. 

A man who was a patient in the out-door department of the N. V. State 
Hospital for Diseases of the Nervous System, and who had been treated 
by my confrere, Dr. J. .1. Mason, tor epilepsy for a long time, was subse- 
quently discharged, as it was supposed, cured. A month or two after- 

1 Med. Times and Gazette, July •-';>. L874, 



316 



BULBAR DISEASES, 



wards, having an attack which was undoubtedly epileptic mania, he pur- 
sued his wife through the streets, and. drawing a pistol, shot Iter through 
the heart. After the deed he expressed great remorse, and gave himself 
up to the authorities, but, notwithstanding the medical testimony, was 
sentenced to the State's prison for life. 

Causes. — Of the one hundred and eighty-three cases of epilepsy I 
have s.cn at various times, the ages at which the disease appeared were 
as follows : — 



Under 10 years 
Between 10 and 20 years 
Between 20 and 30 " 
Between 80 an.] 50 " 

Over 50 " 



Male. 
1G 
23 
27 
29 
4 l 



Female. 
10 
48 
14 
11 
1 



Total. 
26 
71 
41 
40 
5 



99 



84 



183 



Reynolds and Hammond show very much the same result. The former 
saw one hundred and seventy-two cases, and the latter live hundred and 
><'\ enty-two. 

Hugon* has recently made a valuable addition to the literature of epi- 
lepsy in an excellent brochure upon the subject of etiology. 

lie gives ;i table prepared by Martinet to show the proportion of cases 
beginning between the 10th and 20th years. 

Of 307 cases collects 

.. 68 .. 

« g3 .. 

-• 306 " " 

« 106 (< « 

• • 280 " " 

I;; •• " 

•• 70 •• " 

■• 75 •• " 

It will therefore be seen that nearly half of all the cases begin before the 
twentieth year. Bean collected 273 cases, b> of which began between the 
6th and 12th years; 19 between the 12th and L6th years; and 17 be- 
tween the L6th and 20th years. 

The attack- of early life are exceedingly irregular, and may begin as 
poorly developed paroxysms, which are by many classified under thai 
mosi convenient term eclampsia, which oftentimes means nothing. A 
number of these attacks of an undefined type n-n;ill\ precede the genuine 
ex plosion <»l the real disease. 

In regard t<> sex, it may be said that Beaumes, Esquirol, and Moreau 
were of the opinion thai the disease was mere confined to women than 
men; but on the other band Cejsus, J<>-<'ph Frank, Leuret, and Sandras, 
:i- \\<|| : i- Hammond, Reynolds, and others, take the opposite ground. 



Mussel, there 


were 




. 107 


Herpin, 


c 




27 


Maisonneuve, 


there 


were 


AG 


Alesre, 




u 


. 105 


Leuret, 




a 


42 


Moreau, 




(< 


7(5 


Dunaut, 




U 


. 2G 


Delasiauve, 




a 


17 


Dussart, 




a 


40 



1 lii two of these case* there was an indication of syphilis. 

ur I. ■• ( 'ausea de I'Epilepsie, etc., Paris, 1876, 






EPILEPSY. 317 

From the number of cases I have collected and tabulated) I am inclined 
to adopt the same view as the latter. 

Of HugonV eases, '-V2 in number, 25 Were men. and 7 women. 

Professions seem to have very little to do with the production of the 
disease, if we except bartenders ami Liquor-dealers. 

In regard to the predisposing influence of temperament, climate, and 
season, it has been shown by Foville. Mane. Falret, and Delasiauve, that 
the nervous and sanguine temperaments predispose to the development of 
the disease. Maisonneuve found that of 65 cases, '!■> were of a sanguine 
and 20 of a nervous temperament. Moreau considers that epilepsy is 
more frequent in winter than in summer, while others take the opposite 
view. Whether climate affects the development of epilepsy, I am unable 
to say; but, after very carefully conducted experiments in regard to the 
influence of temperature, I am prepared to state most decidedly that tic- 
attacks are much more frequent whenever there is a sudden change of 
weather. 

A writer in the Revista-Sperimentcde, of Mayer August, 1*7 ~>. has 
given tables showing tin- influence of atmospheric. changes, temperature, 
etc., upon the occurrence of attacks. At that time I began a Beriee of 
observations at the Epileptic Hospital. These, when compared with the 
accurately taken charts of temperature, barometric pressure, wind. etc. 
of the Health Department, conclusively prove the truth of the assertion I 
have just made. The number of attacks seemed to increase ju-t at the 
change ; and a very hot day, followed by a cool one, would show an in- 
crease of from ten to fifteen seizures among my patients during the cool 
day, and vice versa. 

The influence of heredity is more strongly shown in epilepsy than in 
any other nervous disease, except it may perhaps be progressive muscular 
atrophy. In cases of my own the taint can he traced back for several 
generations either by epilepsy, neuralgia, insanity, or other nervous dis- 
eases. In one case the maternal grandfather died insane, the paternal 
grandfather died of apoplexy, the mother was living though subject to 
neuralgia, one brother had chorea, and the other had committed Buicide in 
a fit of temporary insanity. Other examples are very much like this. 
Leuret 2 found among L26 epileptic cases that there was a history of he- 
reditary epilepsy in seven cases. Beau's 3 experience was equally interest- 
ing. Of 278 epileptics, there was hereditary predisposition in 18 c 
Leech and Fox 4 fixed the proportion of epileptics in whom hereditary 
taint was found at 36.8 percent., which, as far as I can judge. is no - j 
geration. Reynolds 5 states that in fhe upper classes this hereditary pre- 
disposition exists to a much greater extent, hut calls attention to the diffi- 



1 Op. cit., p. 7. 

-' Leuret: Etecherches sur l'Epilepsie, Arch. Gen. de Med., 1843. 

; ' Archiv. Gen. de Med., is:;.;. 

4 Manchester Med. and Surg. Reporter, quoted by Reynolds. 

1 Syst. of Med., vol. ii. p. 295. 



313 BULBAR DISEASES. 

culty of obtaining information. I have often been disappointed in getting 
reliable information, for this "skeleton in the closet" is kept closely 
guarded. I have been repeatedly astonished to find how strong this ele- 
ment its in the higher walks of life. In one family I find a long succession 
of insane ancestors, idiot children, and dissolute progeny, which fully 
accounted for the transmission of the disease. It is a fact, however, that 
it does not follow that, because a parent has been epileptic, the offspring 
shall inherit the disease. Voisin found among 96 eases 21 which followed 
hereditary alcoholism and phthisis. It is often due in the first instance 
to exciting causes, which, if removed, would probably be followed by dis- 
appearance of the disease. 

A- to exciting causes, I may enumerate bad habits, excessive venery, 
svphilis, and uterine disease, which last I believe to be one of the most 
important <>}' all. Fright, grief, anxiety, overwork, blows on the head, 
and other traumatisms, also enter extremely into the etiology of the dis- 
ease; and the disorders of digestion and the exanthematous diseases often 
play a part in its causation. Onanism is a very common cause; and of 24 
male cases I have seen during tin' past year, this vice existed in 9. I 
may extract the following data from a paper which I read before the 
American Neurological Association at their lust meeting: — 

One-third of these patients (from the Epileptic Hospital) suffered from 
intercurrent diseases; two had advanced phthisis; several had nephritic 
disease; and a great many were anaemic. In regard to the complicating 
neuroses, I find that twelve were subject to headache, two were hemiplegic 
(right), the epilepsy following the hemiplegia, two suffered from sclerosis 
(one locomotor ataxia, the other diffused cerebral sclerosis), and one was 
an idiot. 

When we came to examine into the causes we found more difficulty than 
we anticipated. The intelligence and memory were much below par in 
all. Scarlatina and variola- preceded the disease in two. syphilis in one. 
In nine the attacks were connected with menstrual irregularities and ute- 
rine disease (versions and flexions), t\\<» of these were masturbators (by 

confession), one of whom lias been cured since the habit was broken. One 
case <»iily was traumatic, four were congenital, and several gave absurd 
answers which were unsatisfactory. These are examples of chronic eases, 

and of course many are intractable. 

Morbid Anatomy and Pathology The variety of morbid 

appearances that have been found from time to time give no satisfactory 
explanation of the pathology of this disease, and we will not enter exten- 
sively into their discussion. Spicula of bone growing into the brain-sub- 
Btance, thickened meninges, deformities, <>r depressions of the cranial 
bones, vascular anomalies, cysts, tuberculous deposits, softening, and a host 
of other changes have been observed. Some of these are important 
appearances which Bhould not be dismissed too hurriedly. Undoubtedly 
the osseous changes are quite Satisfactory causes. In three cases 1 Found 
Bpiculae or nodules or bone growing into or pressing upon the cerebrum. 
J i j oic of these the exostosis had attained a length of one inch, and varied 



EPILEPSY. 319 

from one-eighth to one-quarter of an inch in diameter. In other cases I 
have seen decided depressions of the parietal bones, which infringed to a 
great extent upon the brain-substance beneath. As tar a- the deep Lesions 
iro, nothing very conclusive has been found. Van-der-Kolk has dwelt 
at length upon the increased vascularity of the medulla and the softened 
patches sometimes present, but these changes are jusl as likely to !><• the 
results of the disease as they arc to be the Lesion which produce- the 
convulsion. 

It seems likely, however, that the investigations of Cazauvieilh and 
Bouchet. Bourneville, Charcot, and Delasiauve in Franc*.', as well as those 
of Meynert in Germany, must throw some Light upon the pathology of 
this puzzling disease. All of these observers found distinct induration of 
the cornu ammonis, or pes hippocampi, which is known to lie Bituated 
in the lateral ventricle. Cazauvieilh 1 reports eighteen autopsies made at 
La Salpetriere. In nine of these one or both of the cornua ammonis 
were indurated, and at the same time there was induration of the white 
matter of the hemispheres. Bouchet, 2 in forty-three<jases, found the same 
condition of affairs. lie says. " La cornc d'ammon est la partie cerehralo 
qui a le plus frequemment presente* rinduration. Cette alteration a 
souvent etc si frappante, et quelquefois si constante, que bien eVidente 
nenf fois de suite pour quelques medeeins assistants, elle leur a donne la 
conviction qu'elle representait exactement la cause pathologique de l'epi- 
lepsie." 

Bourneville observed this lesion five times out of thirty-four during the 
years L866— 1874. Meynert has repeatedly discovered induration of this 
part, and considers it a pathognomonic sign. In his examination the 
cornua ammonia were found atrophied, and appeared to be of a cartilagi- 
nous hardness, and had undergone a general alteration. 

Often autopsies that I have made, six presented this lesion, and in one 
I found it to be uncomplicated. The other four cases presented nothing 
distinctive. In two the left hippocampus major was indurated, in three 
both were indurated, and in one the right was the seat of the same change. 
In one o\' these the extreme exterior part of the pes hippocampus was 
quite firm; the little crenatious or irregularities were more marked than in 
the healthy brain, as there had evidently been some atrophy with contrac- 
tion. In one the gray matter just adjacent to the hippocampus major con- 
tained several indurated patches. In two cases the veins which skirt the 
inner cd<j;r of the corpora Striata at the line of the velum interpositum, and 
receive branches from these bodies, were quite distended with blood, as 

were the venae galeni. The white matter in both anterior LoDOS was quite 
hard in three cases. In one case there were minute extravasations throughout 

the brain and in the medulla. In two cases there was etfusion into the 



1 Aivi.iv. Gen. de Med., Sme Am c. 1825, i.. ix.. p. BIO, et 4me Anno. 

i.. v.. p. .-). 
1 Sur l'Epilepsie (Annates Med. Psychologiques, 1853, 1. v.. p. 209). 



320 BULBAR DISEASES. 

lateral ventricles. The cranial bones in one case were found to be con- 
siderably thickened. In all of the cases there were evidences of great 
meningeal hyperemia. In three of these eases I found microscopical dis- 
organization of a granular character of the nerve-elements in the medulla. 
The vascular walls were thickened, and at certain points ruptured, the 
places of rupture having no special pathological relation as far as the 
nuclear involvement was concerned. 

In three cases which are not included in the ten referred to, I found 
osseous growths. Although this lesion of the cornua ammonis very rarely 
exists alone, it seems to be quite a constant morbid appearance, and it 
now remains for us to discover whether the condition is peculiar to 
epilepsy. 

Epilepsy is, without doubt, an organic affection, the established disease 
beginning, perhaps, after a peripheral irritation has been transmitted re- 
peatedly to the centres; but after the disease is fairly developed, the con- 
vulsions are not necessarily produced by the excitement of such distal 
irritation : for. as Nothnagel shows, in cases dependent upon a cicatrix 
the attacks are not, as a rule, excited only by irritation of the cicatrix. 
The clinical features of the disease prove the truth of this rule; for, in 
any well-established case, gastric, uterine, or any other reflected irritation 
may give rise to the seizures, or they may take place in an apparently spon- 
taneous manner. We must, therefore, consider that epilepsy is a disease 
of an organic character, expressing itself after either some distal or central 
stimulation in an irregular manner, or the result of both. That it is 
connected with central changes there is no reason to doubt; though these 
changes are by no means uniform. 

The experiments of Brown-Sequard have thrown much light upon its 
pathology, though Nothnagel and others do not accept his views in their 
entirety. Spinal epilepsy, which has been described by Brown-Sequard 
:,- an independent and local affection, is thus spoken of by Nothnagel: 
-Of course, if we lise this designation (spinal epilepsy) for those cases 
i,, which an actually existing epilepsy i- developed in consequence of 
mi affection of the spine, it would have a certain justification. Still it 
IS superfluous; for here the name of secondary epilepsy, as above pro- 
posed, i-. in our judgment, amply sufficient. We must, however, very 

decidedly protest againsl the abuse which has recently come into vogue of 
describing a- Bpinal epilepsy the clonic and tonic spasmodic seizures \\ hich 

,„.,.,,,. ftg ; , symptom in Bpinal affections, which remain confined to the 

extremities or even i<> the Legs, and are not accompanied by any trace of 
mental changes. With jusl a- much propriety could we -peak of a Bpinal 
. „,, n or median epilepsy in the case of clonic twitching- of the mus- 
cles of th<- fingers or neck which proceed from a peripheral affection of 
the median or Bpinal accessor} nerve. In our opinion it i> most judicious 
,,, |,| the expression fall entirejw into disuse; for on one hand it is unne- 
cessary] and, on the other, it leads only to confusion." 

The experiments of Brow n-Sequard were chiefly made upon guinea-pigs. 
II,. produced epilepsy l>.\ dii ision of the trunk of the Bciatic, internal pop- 



EPILEPSY. 321 

liteal and posterior roots of the nerves innervating the lower extremities, 
and by injury of various part- of the brain, the corpora quadrigemin?, 
and cerebral peduncles. He also divided the cord at different points par- 
tially or completely, and found that injury of the lower part of the cord 
seemed to have more to do with the subsequent epilepsy than when the 
upper part was mutilated. After these experiments, the first appearance 

of epilepsy occurred in from four to six weeks. The attack- weir either 
spontaneous, or followed irritation of certain parts of the >kiu which were 
included in the so-called •• epileptic or epileptigenous zone.*' This in- 
cluded the cheek, anterior part and side of the neck, and a portion of the 
hack. This region became anaesthetic, and the hair usually fell out. Any 
irritation of this tract, such, for instance, as pinching, gave rise to an at- 
tack. Ultimately the anaesthesia diminished, and the attacks subsided, so 
that it was impossible to excite them. The " epileptic zone" corresponded 
to the side upon which the nerve or cord injury had taken place. 

Other forms of experimentation have produced convulsive attacks, or a 
condition resembling epilepsy. These were blows upon the hack of the 
head (Westphall) ; irritation of the cortex-cerebri (Hitzig) ; ligation of 
the carotids and vertebral arteries (Cooper. I lull . Kussmaul. and Tenner); 
irritation of the peripheral sensory nerves (Nothnagel, Krauspe). The 
labors of these, as well as others, indubitably show that the epileptic at- 
tack is connected with cerebral anaemia, and the experimental production 
of this vascular state when irritation of peripheral sensory nerves has been 
made furnishes another link in the chain. 

The question of localization next arises. Brown-Sequard. Schiff, Rey- 
nolds, and Kussmaul. and Tenner have all demonstrated that the me- 
dulla oblongata is the probable pathological seat of the disease. It has 
been proved by them that a so-called •• convulsive centre" is here located. 
which, when excited by reflex stimuli, gives rise to extensive spa-ms of 
both kinds of the voluntary muscles : that whether the irritation come- 
ex chorda or ex ccrcbro. there is a primary bulbar congestion, a cerebral 
anaemia, and a secondary cerebral congestion ; that such congestion follows 
reflex spasm of the cervical muscles, and that a condition of venous en- 
gorgement ensues from pressure upon the large vessels of the neck. The 
pathology of the confirmed disease may be briefly stated a- — 

A. The existence of a condition of reflex excitability of the medulla 
from a Long-standing reflected irritation. 

P>. An exciting impression transmitted from the periphery, or from a 

central part. 

('. The irritation of the vaso-motor centre (described by Dittmar and 
others) through congestion at the floor of the fourth \eutricle. 

1). A secondary anaemia ami byperaemia of the hemisphere 

The production of symptoms is probably due to — 

1. a. Anaemia of the brain ; (. Consequential primary loss of conscio a- 
Hess, etc. 

2. Irritation of " convulsive centre," with tonic muscular contraction. 
•">. </. Irritation of nuclei of lower cranial nerves; b. Consequential 

21 



322 BULBAR DISEASES. 

asphyxia. Contraction of muscles of neck, pressure upon vessels, etc.. 
secondary stupor, clonic convulsions. 

Yan-der-Kolk 1 explains the tongue-biting as the result of irritation of the 
nuclei of the hypoglossal nerves. 

The observations of Hughlings Jackson 2 and Hitzig throw much light 
upon the pathology. The former proves " that those parts are wont to 
suffer first and most which serve in the voluntary (special) operations, 
and those last and least which serve in the more automatic (general opera- 
tions ."• 

Briefly to illustrate this, he quotes from an article in the Lancet, 
demonstrating that the three points at which the convulsions often begin 
are : " (1) in the hand ; (2) in the face, in the tongue, or both ; (3) in the 
foot." 

This confirms the idea that the onset begins in the parts devoted more 
particularly to the execution of voluntary movements. lie has been 
enabled to prove that in this manner the parts first attacked are those 
which are more commonly affected in hemiplegia. He also calls attention 
to the phenomenon of aphasia, with epilepsy beginning in the right cheek. 

" Epilepsies," he says, " are the results of the second class of functional 
changes; they are, speaking briefly, discharging lesions. But there are 
many varieties of discharges. Defined from the paroxysm, an epilepsy is 
a sudden, excessive, and rapid discharge of gray matter of some part o\' the 
brain ; it is a local discharge. To define it from the functional alteration, 
we Bay there is in a, case of epilepsy, gray matter which is so abnormally 
nourished that it occasionally reaches very high tension and very unstable 

equilibrium, and, therefore, occasionally explodes It will be 

observed that the discharging lesion of epilepsy is supposed to be & perma- 
nent lesion; there is gray matter which, since it is permanently under 
conditions of abnormal nutrition, is permanently abnormal in function. 
That this permanent abnormality is a varying state, has been said ; it has 
been remarked that the gray matter occasionally reaches high tension, 

and. therefore, occasionally discharges (or is discharged). There are 

waves of stability and instability. It follows from this that the first lit is 
supposed to be a discharge of a part which has for some time before been 
in a slate of malnutrition ; and a still further inference is that such 'causes' 
of epilepsies as fright are only determining causes of the first explosion. 
Many of the premonitory symptoms of a first attack are probably results 

ofslighl discharges; they are miniature fits" 

That irritation of the auditory apparatus may give rise to a. variety of 
epilepsy there can he no doubt, hut such cases I believe lo he rare. 

Brown-Sequard 1 states that Mr. Hinton, an English surgeon, has reported 
leveral where, after death, no lesion was discovered, except evidences of 
disease of the middle ear. MyJHend \)v. Roosa tells me that out of five 



1 Brain and Spinal Cord, Sydenham Trans. 
•' \\ . Riding Reports, vol. hi. p. S15, et seq. 
Central Nervoiu System, p. 96, and Gaz. Mel. de l'an>, is 12, p. ■_'.». 



EPILEPSY. 323 

or six thousand cases of aural disease he has seen, he does nol remember 

but one of this kind : — 

John W. P , aged 15 years and 6 months, a stout and apparently 

healthy boy, well nourished, and presenting do external evidences of dis- 
ease; family history good. His mother stated that he had always been 

a rather dull boy, and that at school he whs generally behind in his studies, 
and did not seem to learn easily, and when sent on errand- he was unre- 
liable aitd forgetful. There is no history of injury or sudden fright, nor 
Las there been any known predisposing or exciting cause, bul at th< 

of eight years lie bad a severe attack of scarlatina, which left him with a 
remaining otitis, most severe on the right side, and resulting in a profuse 
discbarge of pus. which still continues in a modified degree, but is not so 
excessive as it was a month ago. About six weeks ago he began to Byringe 
his ears with a carbolic acid solution, which had the effect of removing a 
large mass of what was probably inspissated pus; and his hearing, which 
bad before been quite detective, became greatly improved, and he no longer 
complained of various subjective noises, such as buzzing and roaring. 
When the quantity of discharge was diminished his ears became painful, 
and pressure on the mastoid processes caused much Buffering. Ever since 
the scarlatina he has had frontal and occipital headache, which is always 
constant. About a month ago he had his first epileptiform attack, ami 
this occurred about noon one day when he was using his syringe. Without 
warning be suddenly tell to the tloor. became convulsed, and in a few 
minutes recovered, and did not fall asleep; but a semi-unconscious state, 
however, supervened. 

The next attack came on four days after, at 3 P.M. While be was 
chatting with a friend, be suddenly stopped talking, and fell. This attack 
was much more violent than the tirst one. They now become more and 
more frequent, until about two weeks ago, when on one occasion he had 
fifteen during twenty-four hours. Since then he has not had so main - , 
having had between one and five attacks every day but one, which was 
the only day he missed the attack since the commencement. During some 
of the attack- he is very violent, while in others not SO much so. His ap- 
petite has been irregular for some time past. An examination made by 
Dr. Baldwin, House-physician of the Epileptic and Paralytic Hospital, 
and myself, revealed tenderness on pressure over mastoid processes, but 
mostly on the right side. He has had no definite aura, but peculiar sensations 
which he cannot describe, preceding his attacks, lie complains of vertigo 
and nausea, and muscular weakness after the slightest exertion. He in- 
variably return- to consciousness almost immediately after the attack, at- 
tempts to rise and walk, but is usually quite feeble. 

Examination of Ears. — R.: Discharge scanty, thin, and sero-p undent ; 
and. on examination, the niembranuin tympani is found absent. The tick 
of a watch is heard only when the watch is pressed against the car. A 
roaring sound is always present. 

L. : The same examination shows more or less congestion of the tympa- 
num, with evident signs of otitis media; but there is qoI SO much pain on 
this side, and the hearing is better, the ticking of the watch being heard 
at three inches. 

Patienl has complained lately of deep, severe pain in the frontal, 
but extending back to the occipital region. With this pain there is 
dizziness, especially when he stands, thus making it difficult for him to 



324 BULBAR DISEASES. 

preserve his equilibrium, which is Btrikingly shown by his irregular move- 
ments. When Bitting up in bed, he complains that objects move up and 
down, and not horizontally, as we should expect to find in ordinary audi- 
tory vertigo ; and a very interesting and peculiar symptom are the niove- 
ments he makes to preserve his relation with surrounding objects, his body 
moving up and down and his head swaying strangely. lie is very suscep- 
tible to Qoises and bright lights, either being capable of inducing a spasm 
at tiine>. Vomiting from an empty stomach is occasional, with dilatation 
of pupils. The vision of right eye is at times entirely lost, but at others 
is unimpaired. Muscse volitantes are frequently complained of. Exami- 
nation of urine affords negative results. 

Observations during an attach or convulsion, which occurs at no regu- 
lar intervals^ hut is a constant result of irritation of the internal auditory 
apparatus: — 

Ear syringed at 9.55 A. M. Patient calm, and not at all nervous ; 
-kin of normal hue; pulse regular ; temperature normal ; pupils somewhat 
dilated. lie passed a good night, and suffered but little pain, though his 
vertigo was still troublesome. He was placed upon a bed, and the point 
of an ordinary two-ounce syringe, filled with tepid water, was inserted in 
the external meatus of the right ear, and the contents gradually expelled. 
This caused some pain and dizziness, which increased as more water was 
injected ; and when one ounce had been thrown in, the patient became 
suddenly unconscious, and the head was drawn from one side to the other 
by rapid clonic contractions of the muscles of the neck, and almost at the 
same time the convulsion became general, the muscles of the back being 
extensively involved. 

About five seconds after this, there were clonic spasms of the muscles 
of the jaw, so that the patient snapped his teeth, and, at the same time, 
forcibly inspired, giving vent to a, peculiar noise which might be easily 
compared, by a person of lively imagination, to the bark of a dog. 

This paroxysm lasted two minutes, and during its continuance the pupils 
were widely dilated. The patient remained unconscious: but there was 
neither pallor nor suffusion of the face. Thirty seconds afterwards, a 
period of muscular relaxation succeeded, afresh attack followed, during 
which there was more marked opisthotonos, much more noise, but no 
frothing at the month. Pupils still dilated, though perhaps not so much 
-<> ;i- ;ii first, while the skin was slightly suffused ; but there was no duski- 
ness. Duration, one and a. half minute. Ten o'clock and thirty seconds, 
after slight relaxation and subsidence of movements, the lateral jactitat ion 
of the head again began ; and at ten o'clock and one minute a violent ac- 
< » 1 1 of clonic, and afterwards tonic spasms made their appearance. 
The eyeballs had throughout been uncovered, and at first were stationary 
and immovable, or almost so; but now they were agitated by nystagmatic 
movements, and the pupils were dilated. This paroxysm lasted but thirtj 

Seconds. At ten o'clock and three minutes there was another seizure, 

during which the left sterno-cleido-mastoideus was involved in a prolonged 
tonic contraction. The pupils now partially returned to their normal con- 
dition, which was one of slight dilatation; and at ten o'clock and four 
minutes the patient became Benn-conscious, answered questions in mono- 
syllables, and after a few minutes recovered entirely. The pulse Buffered 
no variation, except, perhaps, after two minutes hail elapsed from the be- 
ginning of the seizure, when ii Beemed to increase in volume, and perhaps 
slighth in rapidity. There was an entire absence of any external 



EPILEPSY. 325 

evidence of asphyxia, which is so marked in the more familiar form of 
epilepsy. 

I have ascertained that the convulsions may he precipitated by -imply 
blowing into the external auditory meatus. 

Diagnosis. — Epileptic attacks may be mistaken for the convulsions 
of Bright's disease, infantile convulsions, hysteria, alcoholism, opium 
poisoning, syncope* and softening, and the disease is occasionally simu- 
lated by malingerers and others. I may briefly dispose of the above : 

1. Uraemic convulsions are generally preceded by droVsmess or coma, 
delirium, and stertor. The limbs may be ^edematous, and the mine con- 
tains albumen. 

2. Infantile convulsions from worms, dentition, and other eccentric 
causes, are usually attended by a febrile condition. The convulsions are 
of short duration, and are characterized by complete loss of consciousness. 
The discovery and removal of the cause usually effect a disappearance of 
the attacks. 

3. Hysteria. (Sec article Hystero-Epilepsy.) 

4. Alcoholism and opium poisoning are characterized by a more pro- 
tracted stage of unconsciousness and a contraction of the pupils in the latter. 

5. Fainting attacks may resemble the petit-mal, but there are no 
spasms, and the pulse is feeble. 

6. Softening and other organic states give rise to convulsions, but the 
accompanying symptoms should enable the observer to make the diagnosis 
in every instance. 

Simulated convulsions may deceive a careless person, but the normal 
condition of the pupil, and the eagerness of the individual to play his part 
perfectly which he does not do, lead to the detection of the imposition ; 
and the excessive pallor of the first stage can never be simulated. 

The syphilitic form of the disease resembles much the ordinary variety, 
but in some instances it is of the greatest importance to distinguish its 
specific nature, as of course the treatment is entirely different from that 
employed in the non-specific disease. Buzzard, who has given us an 
admirable little work on the syphilitic neuroses, lays great stiv>> upon the 
necessity of recognizing the variety of pain as a differential symptom. 

"If pain in the head be associated with convulsive attacks." he says, 
" it generally precedes the attack in syphilitic convulsions, and is often 

localized in one particular spot In simple epilepsy (if it be 

present) it almost always follows the lit, is diffused over the forehead, and 
is at no time a strongly marked symptom." The age of the patient, and 
the time from which the attacks date, are also of great importance in this 
connection. It is not probable that syphilitic epilepsy would begin early 
in life, or, at least, before puberty, but simple epilepsy dates from early 
childhood. 

Prognosis. — The duration of the disease has much to do with the 

prognosis, and the mode of origin, form of expression, and complicating 

conditions must all be considered before an opinion is given. If the 

disease be of idiopathic origin, or if it be due to violence, i. c, injuries to 



32G BULBAR DISEASES. 

the bead, the prognosis is bad. If it be due to eccentric causes or syphilis, 
there i< reason to be hopeful. Hereditary predisposition is an obstacle in 
our path which sometimes blocks the way to a cure. I have found that 
the petit mat is also less amenable to treatment than the severe form, 
and thai it is pretty sure to produce an impaired mental condition. 

Reynolds thinks that the attacks which recur rapidly are more amenable 
than those which take place at long intervals, but this has not been my 
experience. If there be any considerable congenital lack of intelligence 
the ea>e may be considered as incurable. The unfavorable conditions are 
the occurrence of a great many attacks in a short space of time, the biting 
ot* the tongue, and a condition which has been known as the "status epi- 
lepticus," in which there are a comatose condition, and a number of fits 
in close succession. Death from epilepsy is not common, and I know of 
but six fatal cases: five from the disease, and one from falling upon a 
sharp iron point which penetrated the orbit. 

Treatment. — Before entering upon the discussion of particular modes 
of treatment, 1 desire again to refer to certain etiological facts which bear 
to a great extent upon the selection of remedies. 

I may be pardoned for calling attention to practical points which 
may appear unimportant to some; but an experience gained from the 
management of a great many cases teaches me that they are to be carefully 
considered in selecting a plan of treatment. These simple indications, I 
am convinced, are too often overlooked even by painstaking and careful 
medical men. I allude to the necessity for discovering the exciting cause. 
I am every day made to feel that the idiopathic cases do not form so large 
a proportion as they were once thought to. With this belief 1 am satis- 
fied that empiricism and routine management are had methods. Any one 
who examines all his cases thoroughly will recognize the delicate shades 
in epilepsy, variations which are exhibited in other diseases presenting 
more pronounced and better defined symptoms; consequently there are 
evidences of pathological action, which are not always grouped alike, and 
therefore all cases are not lo be treated in the same manner. I ascribe 

the moderate Buccess I bave had in the management of this disease to the 
n cognition of these differences. 

Not only may obstinate epilepsy result from masturbation, but. it may 
he due to many of the diseases of women, and it is produced by eccentric 
irritations of various kinds, or by centric irritation, such as may be asso- 
ciated with toxaemia. 

Sir Charles Locock 1 called attention to nany cases he had treated 
where uterine irritation was the exciting cause.; and I think others have 

had the same experience. In one of Locock's cases the patient was 

affected particularly at the menstrual periods. 

Some of these peripheral causes are curious in the extreme. Through 
the kindness of Dr. Gibney^>f New York, I was enabled to see a child 
who had accidentally injured her ear with her parasol, the br;i<s tip of 
which remained for some time imbedded in the external auditory meatus. 



1 Med. Times and Gazette, Maj -J::, L853. 



EPILEPSY. 32*7 

As a result, convulsions of an epileptic character were caused, and it was 
not until some time afterward that the foreign body was discovered and 
removed. In another case I treated, the epilepsy was unmistakably due 
to a bad habit the woman had of wearing a number of heavy garments 
about her hips, which produced some uterine change. When this condi- 
tion of affairs was noticed, and the skirts removed, she immediately re- 
covered. At the root of many epilepsies, as well as other neuroses, are 
reflex causes — the starting-point being the organs of digestion, or those 
contained in the pelvis. Of course the varieties of epilepsy of an idio- 
pathic nature, or those caused by traumatism or organic disease, will defy 
the best efforts of the physicians. 

In prescribing for our patient there are five indications to observe : — 

1. Removal of exciting causes, if possible. 

2. The diminution of exaggerated reflex susceptibility of the medulla. 

3. Equalization of cranial circulation. 

4. Abortion of paroxysms. 

5. Improvement of general condition. 

For the accomplishment of these, it is imperative that a judicious and 
discreet selection of drugs should be made ; and among those which are 
the most effective I may mention : — 

The Bromides: sodium, potassium, ammonium, calcium, lithium, iron. 

Chloral hydrate. Mercury. 

Belladonna. Arsenic. 

Digitalis. Amyl-nitrite. 

Strychnine. Tri-nitro-glycerin. 

Ergot. Cod-liver oil. 

(FF. 23, 84, 29, 44, 77, 7G, 43, 85, 86, 32.) 
I have not classified these remedies, as it is unnecessary to do so ; but 
will now say a word in regard to their usefulness. 

No one drug can be declared a specific, as I am sorry to see has been 
done; and we must not be too eager to accept the sanguine results of 
certain over-enthusiastic authorities, and be governed thereby. I allude 
more especially to the almost universal use of the bromides to the exclu- 
sion of everything else, and also to their employment in quantities which 
often ruin the patients, or, at any rate, produce a condition of diminished 
vitality, which is inconsistent with any hope of success. KadclirteV idea 
in this respect is a good one: " There is reason to believe thai the thera- 
peutics of convulsion must be based upon the notion that vital power has 
to be reinforced, and not upon the contrary opinion." What the proper 
dose is has not been clearly settled by any one. There are neurologists 
who believe in toxic doses, and there are others who prescribe quantities 
which are almost small enough to be inert. In England it has been the 
custom to prefer the very small doses. I have seen the prescription o\' a 
very distinguished general practitioner, who thinks five grains of the 
bromide of potassium a. sufficient dose. Ringer 1 recommends from 80 \<> 

1 Pain. Epilepsy, ami Paralysis, p. 215. 

2 Handbook of Therapeutics, p. 92. 



328 BULBAR DISEASES. 

60 -rains in the day: Radcliffe, 1 45 grains ; Russsll Reynolds, 2 30 to 00 
grains ; Bartholow, 8 30 to 240; and Hammond, 4 90 to 240 grains during 

the day. 

Handfield Jones 5 remarks that there is a great difference in the tole- 
rance of individuals in regard to the bromides — some persons not being 
ahl«- t<> stand live grains, while others will not be affected by doses of less 
than forty grains. 

Mv own experience lias taught me that the best effect can be gained by 
the repeated administration of sixty grains in the twenty-four hours. The 
larger doses produce rapid bromism, Avhile the medium dose seems to be 
better appropriated, but will do just as much mischief in the way of 
bromism as the larger ones, if given for a length of time. My records 
show me that the average time for development of symptoms of this kind 
is about three months, while anaesthesia of the fauces is produced in a, lew 
w « eks, or even a much shorter time ; and I agree with others that it is 
necessary to produce this condition before we can say that the medicine 
has produced its physiological effect. But when once reached, the further 
toxic action of the drug is deleterious instead of beneficial. Brown- 
Sequard considers the appearance of acne to be an indication that the 
medicine has begun to do its work, in which opinion he is joined by Dr. 
Putnam-Jacobi. 6 Voisin 7 considers the " point of saturation to be indicated 
by the anaesthesia of the pharynx and nares, so that in one case nausea, is 
not produced by tit-illation with a spoon, and in the other sneezing ami 
weeping do not follow the introduction of a straw into the nasal cavity." 
I should consider the latter a rather severe test. According to Danton, 8 
the bromides act as vascular medicaments, diminishing exci to-motor 
power. They act on the unstriped muscular fibre, producing local anae- 
mia, and moderating excitation resulting from temporary or permanent 
congestion. "They are agents that pass very rapidly into the blood 
(Ringer), 8 and consequently their effects are very immediate, and they 
accumulate till the point of saturation is reached before they are elimi- 
nated in anything like considerable amounts." We are all aware that 
repeated and large doses of these drugs are followed by a, most disagreea- 
ble and pernicious Btate of affairs. Voisin 10 has referred to two forms of 
bromism, which he has divided into the slow and rapid. In the first the 

complexion becomes muddy, the eyes sunken, sight and hearing poor, and 

memon obscure. The patient cannot write, and cannot express himself, 

' Op. cit., p. 202. 

2 Op. cit., p. 828, vol. ii. 

:i Materia Aiedica and Therapeutics, p. 871. 

4 Clinical Lectures on Nervous Diseases. 

r ' Functional Nervous Disease, p. 325. 

1 Oral communication before Am. Neurological Association, 

7 Voisin, \relii\. de .\[f-i Iccine. Jan, IS7.'!. 

• Danton, These de Paris, 1874. 

" Op. cit., p. 91. 
\ oison, Archiv, de Me* lecine, dan. 1878. 



EPILEPSY. 329 

as he forgets words; there is tremulousness. In the other variety of the 
slow form there is dementia, or delirium with maniacal outbursts. Ataxia 

is also a feature of this variety. In the rapid form — thai with which we 
are most familiar — somnolence, headache, uncertain walk, difficulty of 

speech, loss of expression, " fishiness" of the eye*, drooling of saliva, etc. 
etc., are the ordinary symptoms. 

Various grades of toxaemia, or even a state which Voisin calls the 
" cachexie hromique," and which terminates in a typhoid condition, may 
result from a reckless use of this drug. 

As regards the variety of bromide, I think the sodie is the mosl reliable 
and stable, the potassic salt varying very much in strength. The others 
either have a, tendency to deliquesce, or are expensive. It will be advis- 
able to keep the solution in a tight- stoppered bottle, and have fresh quan- 
tities put up constantly, as it is very apt to undergo changes — in which 
the bromine is evolved. And now a word regarding the time of adminis- 
tration. It has been shown repeatedly that these salt- are much better 
absorbed when the stomach is empty. I have found also that a heavy dose 
at night is apt to do more good than if the amount prescribed is equally 
divided up through the day. In a great many patients I have found the 
attacks to occur at the waking hour, and I suppose this is due to the sudden 
change in the cerebral circulation. A mild diffusive stimulant has oxer- 
come this, and in many cases warded off the attack. I direct my patients 
who have their convulsion at this time to keep a glass or a small quantity 
of spts. ammonias aromaticus near at hand, to be taken before rising. 
Cold douches to the head are valuable. If the attacks be irregular, it will 
be found necessary to divide the dose. 

The treatment of the disease in women should be directed as well to the 
pelvic organs. It will be found that the bromides will markedly affect the 
flow, and relieve the pain or uneasiness which is connected witli the men- 
strual period. Locally I have found that cold applied for a few minutes 
daily over the ovaries will modify the attacks should they lie connected 
with irritation of any of the pelvic viscera. The progress of the disease 
should be soon modified by the doses I have recommended; and it will be 
seen by the table condensed from that prepared by Dr. Hollis, 1 that even 
smaller doses modified or cured the majority of the cases lie cites. At the 
Epileptic and Paralytic Hospital, where most of the cases are the very 
worst that can be collected as regards chronicity, I find that sixty grains 
a dav will cut short the attacks of a. great many patients, ami I have 
cured a number of private patients by this method. Dr. Hollis 1 cas< s 
were not selected, and are evidently hospital patients, like my own. 



British MedicalJournal, duly 1, 1876, p. -i. 



330 



BULBAR DISEASES. 



Analysis of Eleven Cases of Epilepsy. 
S. B.— Sodic bromide. P. B. — Potassic bromide. 



S3 

- 






Average 














No. of 










»: 


i lid 


Duration of 


attacks 


Maximum 


Minimum 


Diminu- 


Eemarks. 


■ 


age. 


disease. 


before 


dose. 


dose. 


tion. 




to 






treatment. 










1 


Male, 15 


Since birth 


1-2 weekly S.B. err. xx. S.B. gr. xv. 
t. i. d. t. i. d. 


2 in s weeks Weak intellect. 


2 


Male, 22 


Two years 


1-2 weekly S.B. gr. xv 


1 in 20 w'ks Disease followed 












sunstroke; treat- 












ment lasted three 












months. 


3 


.Male, 2J 


One year 


1 or more SB. xxv., S.B. gr. ij. 


None in S 


Hard drinker, 








in we k. 


P.B. gr. 


weeks 


feeble intellect : 








s imetimes 


XXX. 






p itassinm salt 








many in a 
day 

1-2 weekly, 








inert. 


4 


Female, 2 


IS months 


Very small 


None in S 


Fits followed den- 








sometimes 


doses 


weeks 


tition : rickety 








3 in a day 






constitution. 


5 


Female. 18 


One year 


1 in week 


S.B. gr.xxx Gr. xx. 


None in 4 
weeks 


Tuberculous dis- 
eaBe. 


6 


Male, IS 


Five years 


4 in week 


S.B. gr. xv 


None from 5 No affection of 
weeks | intellect. 


7 


Female, 11 


Five years 


2-3 in week 


S.B. gr. xx. S.B. gr. xv. 


1 in .") w'ks .Followed a blow : 
subject to h.ead- 
1 ache. 


8 


Female, 17 


Several 


Sometimes 


S.B. gr. xv 


None after Has bitten tongue 






months 


4-"> daily 




treatment 




9 


Male, 20 


19 years 


2-3 weekly 


S.B. grr. xl. S.B. gr. xv. 


No fits for 

2 weeks 


No aura. 


10 


Male, 13 


Two years 


3 weekly 


S.B. gr.xxv S.B. gr. xv. 


1 in 3 w'ks 


Well developed 
disease, facies 
epileptioa well 

marked. 


11 


Male, 2-> 


11 years 


1 in 2 weeks 


S.B. gr. xx. 


1 in o w'ks No tits sine 1 be- 
ginning of treat- 
ment. 



By this table it will be seen that from fifteen to twenty grains of the 

Bodic -alt wen- required to immediately <Jecrease the number of attacks. 

Below will be found two tables. In one are tabulated the interesting 
features of twelve cases of epilepsy. They are old hospital patients, and 
had applied for admission after outside treatment had been exhausted. 
Even here the bromides, in the doses 1 have given, seem to do much for 
the sutferers. Traumatism and actual insanity make the prognosis as bad 
as it well can l»e, and treatment is simply palliative. Large doses have 
aggravated many of these cases. 

The other observations are selected from my note-book, and are illus- 
trative of the efficacy of the dose 1 have advocated, Bromism occurred in 
Bpite of all 1 could do in most of them, though it was a mild form and 

under control. The patients were all of the better class, and of course 

had all the advantages of comfortable homes, attentive friend.-, substantial 
food and good air, although many of them were inclined to over-eating, as 
in fad all epileptics are. in thi- respect there is an advantage in favor 
of the poorer patients, who cannol obtain rich food. 



EPILEPSY. 



331 






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332 



BULBAR DISEASES. 





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EPILEPSY. 333 

And now regarding the large doses. l\' the idea is to thoroughly ruin 
the patient's health, enfeeble his mind, or perhaps drive him to an asylum, 

the toxic administration maybe indulged in. It is very true thai some- 
times a rapid restoration may be brought about by "iron and quinine;' 9 
but there are many eases where the recovery is not quite bo complete as 
one could wish for. Memory is enfeebled, and there is a cachexia which 

remains for an indefinite time. ■ A darker side of the picture is not always 
displayed when brilliant results are detailed. This is the list of demented 
and those that Lave died. My friend, Dr. Janeway, was present at the 
autopsies of two patients who died brominized, for certainly the examina- 
tions disclosed no other cause for death. I myself have seen several 
demented cases, and I have no doubt others could tell the same story. I 
have used the bromides in combination with chloral hydrate, and have 
obtained the most excellent effects. Such good results as diminished stu- 
por and eruption follow the administration of equal parts of chloral and 
the bromide of sodium. 1 

Belladonna and its alkaloids are of great value when the seizures occur 
in the daytime, or are of the variety known as petit mat. I have injected 
the sulphate of atropia in - (T l ? gr. doses beneath the skin at the back of the 
neck with good effect, and have used it in the manner directed by 
Trousseau. In either way it should be administered until dryness of the 
throat is obtained, and should be given a patient trial. The property 
possessed by belladonna, of blunting reflex susceptibility assures it a great 
advantage over other methods of treatment, when there are centres of irri- 
tation such as in gastric epilepsy. 

In ergot we have a remedy which controls the cranial circulation much 
more readily than any drug with which I am acquainted. As the object is to 
diminish the congestion at the floor of the fourth ventricle, its combination 
with the bromides greatly increases the action of the latter. Ergotin may 
be given alone in the form of Bonjcan's capsules. 

To Tyrrell 2 belongs the credit of suggesting strychnine. He believes 
that this remedy controls excitation of the medulla, oblongata. In one 
individual who averaged fifty-one attacks in a month, the number was 
reduced by the strychnine to eleven in two years. Handheld Jones does 
not favor the remedy, nor do others, although it has advocates in this 
Country. In small doses it certainly does good; but I have found that in 
larger doses than -fa gr., ter in die, it rather aggravates the disease. 

Arsenic is excellent, both for its anti-periodic and alterative action, and 
as an agent to relieve the acne. Clemens, of' Frankfort, has lately advo- 
cated the bromide of arsenic, but in such small doses as to seem useless. 

lie claims for it remarkable virtue when the disease depends U] on idiocy, 

and appears in patients with deformity of the skull. lie reports two 

cures. 



1 While these pages ;irc going through the press tin 1 preliminary report ofthe 

New York Therapeutical Society confirms what 1 have -aid in regard to this 
mixture, which is undoubtedly the best. 
- Med. Times and Gazette, Mai ami August, 1867. 



334 BULBAR DISEASES. 

Where there is an irregularity of heart action, sluggish circulation, 
blueness or duskiness of the skin, I think digitalis is indicated; in fact, I 
generally use it in every chronic case. It is a drug well tolerated by 
epileptics, who can take it in surprisingly large doses. 

An agent lias been lately given to the profession which seemed all that 
was needed at first, but which I am convinced is very much over-estimated, 
except as an abortant. I speak of the amyl nitrite. Drs. Weir Mitchell, 
Zeigler, and Alexander McBride, as well as several foreign writers, have 
praised it. and several cures have been reported. In epilepsy there seems 
to be a "habit" (if I may use the expression) or tendency to periodicity. 
Amy] is well adapted to stop this, as is any other remedy of the same 
class. Crichton Browne alludes to the effects of this drug upon the status 
epilepticus. His patient had had a great succession of fits, and was at 
the point of death; the pupils were contracted to an intense degree, pulse 
1 16, temperature 102°, with stertorous breathing. Voluntary movements 
and yawning were caused by inhalation of the amyl nitrite, and the pa- 
tient subsequently raised his head, looked about him, and recovered. Dr. 
Browne relates ten other cases which were seen with Dr. Mierson. 

\)v. ('. Steketec 1 draws the following conclusions in regard to the action 
of this drug in epilepsy: — 

"It exerts an important influence where the epilepsy is due to or con- 
nected with cerebral anaemia, for the reason that it 'anticipates the attack 
when there are prodromata ; cuts off the attack when it appears; relieves 
symptoms due to interrupted innervation after the attack; and the attacks 
become less frequent* " (? by the author). He also considers it injurious 
where the attacks are due to cerebral hyperaemia, for the reason that they 
last longer ami become more frequent, and when either maniacal or con- 
vulsive, increase in intensity. 

My own experience with amyl nitrite has clearly settled in my mind 
the fact that it lias great virtues in cutting short or averting attacks, but 
that it ha- no permanent influence. Whether we can or cannot make the 
delicate distinctions of Dr. Steketec, future clinical experiences I think 
must decide. Those who have used it say that it does good in a very lim- 
ited number of cases ; and it is a difficull task to decide which are to be 
benefited. I have tried it in every grade of epilepsy, and find in some of 

the worel cases, where the fits occur all through the day with very slight 
intervals, and even where there is time enough to be prepared, that ii is 

often of DO avail. It may be given inclosed in the little glass capsules 

invented by Dr. McBride, of New York, for hospital use, ami for patients 

who ;ire not intelligent, in alcoholic solution. 

1 may he pardoned for bringing another remedy to the notice of the 
profession, and one that has never been used lor this purpose. I allude 

to tri-nitro-glycerine. Its reputation is almost enough to intimidate the 

patient, bul it is as powerful a medicinal agent as it is an explosive. The 
1 Thesis abstracted by Chicago Journal of Nervous and Mental Disease, April, 



EPILEPSY. 335 

tenth part of a drop touched to the tongue is sufficient in a space of time 
which is almost inappreciable to produce a rapid cerebral hyperemia. 
The face is flushed, the eyes become bright, and the temporal vessels 

throb, while at the same time there are marked sensation- of fulness. 
It produces more lasting congestion than doe- amy] oitrite, is much safer, 

and I have found it to act better as an abortant than the latter. Any 
good pharmacist can prepare a solution containing one drop to ten of alco- 
hol. This can be further diluted, so that ten drops of alcohol .-hall contain 
one-tenth of a drop of the nitro-glycerine. It may be kept safe in this 
way, for alcohol prevents its explosion. A dose of a tenth of a drop is 
sufficient in the majority of cases. 

Last of all, it seems almost unnecessary for me to direct attention to 
that most familiar remedy, cod-liver oil, which is so valuable in all nervous 
diseases. 

Anstie treated a number of cases by cod-liver oil alone, and cured seven 
out of twenty patients put upon this plan of treatment alone. In all cases 
I am convinced that it is a valuable remedy which is not appreciated a- it 
should be. 1 have witnessed its great virtues when the bromide cachexia 
was profound, and believe that it should always be used in delicate sub- 
jects. Picrotoxin, a remedy recently brought forward, I have tried, and 
consider valueless. 

The subjects of diet and personal habits are very important ones — par- 
ticularly as the stomach is so often the seat of irritations which are trans- 
mitted to the over-active centres. Beyond the question of over-eating, it 
has been found that a vegetable diet is better suited to this class of 
patients. Mierson, in one of the late volumes of the West Riding Jtrjtorts, 
publishes cases, and makes comparisons between those epileptics placed 
upon a meat and those placed upon a vegetable diet. The results pointed 
to the superiority of the latter. As the greater number of epileptics have 
inordinate appetites, the diet should be strictly regulated. 

It is a good plan, I think, to combine the remedies 1 have alluded to : 
and I take the liberty of presenting a prescription I have used for several 
years :— 

R. Strychnia' sulph. gr. j. 
Fl. ext. ergotse, .^iss. 
Sol. potass, arsenit. 3ij. 
Sodii bromidi, 5 iss. 
Tr. digitalis, giij. 
Aquae me nth. pip. ad ^iv. — M. 
Sig. — A teaspoonful before eating, in a half tumblerful of water. 

If the attacks be of the form known as petit nml. I think either ergot or 
belladonna is our best agent. "With either form of treatment it may be 
found often necessary to use auxiliary general treatment. The BVrup of 
the combined phosphates, or the Byrup of the lacto-phosphate o\' lime, i- 

a good adjunct ; and salt baths, cold head douche-, regular food, early 

hours, and the breaking off of bad habits, will often cure the disease, even 

when it has lasted mam years. 



336 BULBAR DISEASES. 

A- a last resort, should continued medication prove useless, the actual 
cautery or a deep seton at the back of the neck will occasionally arrest 
these bad cases. 

A variety of other remedies have been suggested (and the list of drugs 
alone would till several pages such as this), but as most of them have been 
found inefficacious, I do not think it worth while to further weary the 
patience of my readers. Galvanism, which lias been recommended by 
Hammond, I find to have but Little value. 



1HLBAR PARALYSIS. 

Synonyms Glosso-labio-laryngeal paralysis (Hammond) ; Glosso- 

laryngeal paralysis (Trousseau). 

In the year 18 11 Duchenne 1 first called attention to a peculiar group of 
symptoms which were connected with progressive degeneration of the 
medulla oblongata; and some years later Trousseau 2 noticed it in his admi- 
rable lectures, and presented several cases reported by Davaine, 8 long 
before Duchenne's observations were published, but which were before 
considered to be examples of double facial palsy. Hughlings Jackson, 4 
Dumesnil, 5 Charcot, 6 and Joffroy, Hammond, 7 and lately Dowse, 8 have 
added new facts to the literature of the subject. 

The condition under discussion may be described as a disease character- 
ized by gradual loss of functions of parts supplied by the nerves taking their 
origin from the medulla, though the fifth nerve is rarely affected. 

It may be the result of morbid changes which are limited to the floor of 
the fourth ventricle; or. as this region may be the chance site of sclerosis, 
which affects other parts as well. Such may be the lesion, whether 
" pseudo-bulbar paralysis" (the result of arterial occlusion), sclerosis, or 
glosso-labio-laryngeal paralysis exists; the special symptoms are alike, and 
they appear one after another as the different nerves are involved. 

Symptoms The earliesl expression of the disease is a certain loss 

of power of the lips ; the lower lip especially. If the individual attempts 
to whistle, his efforts may be unsuccessful, and the lower lip hangs so that 
the mucous Burface is largely exposed. The tongue next follows, and its 
protrusion by the patient is a matter of difficulty. The individual is un- 
able to Wring the tip in contact with the roof of the month, and incompe- 
tent to use it in the formation of certain consonants (the Unguals). When 
he tries to speak or read aloud he finds great difficulty in pronouncing 

1 ()]). cit., 2me edit. 

2 Lectures «>n Clinical Medicine, trans., vol. i. p. 908. 
•'' Quoted by Trousseau, vol. i. p. 909. 

1 Philosophical Transactions, pari i.. 1868. 
I ,;,z. HebdomadSre, Juin, 1859, p. 390. 
6 Archiv. de Physiol., torn, iii., 1870, p. 247. 
' Diseases of Nervous System, p, 502 et seq. 
■ Brit. Med. Journ.. Nov. I and i L, 1876. 



BULBAR PARALYSIS. 337 

words containing the letters 1, n, e, d, g, h, j, t, w; and in one of Trous- 
seau's cases the patient could not utter any letter but a. 

He may remain in this condition for some time — say for a year or two, 
when the tongue and lips become more extensively affected ; and not only 
are acts of a voluntary character impossible, but the automatic movements 
of the tongue become almost totally embarrassed. The use of this organ 
in the management of food during mastication and deglutition is much 
impaired, and particles of food become lodged between the teeth and the 
gums and cheek. 

The patient's mouth is generally open, so that his teeth are exposed, and 
from either side trickles a glairy stream of saliva. Next he cannot arti- 
culate the labials, and consequently his speech becomes worse than ever. 

His face wears an inane expression, and he is apt to attract the atten- 
tion of the people in the street by his open mouth and Billy appearance. 
The condition of the tongue has been noted by Dowse ; its papillae become 
atrophied, and the surface very smooth. I have noticed that there i- no 
Loss of the sense of taste at any time. 

The palate next becomes the seat of the paralysis, and the pharyngeal 
muscles are so weak that deglutition is at first difficult, and finally impos- 
sible. 1 Fluids are especially troublesome to swallow, and are apt to be 
regurgitated through the nares, and the voice becomes nasal and metallic 
as the upper part of the vocal apparatus becomes involved. 

The facial expression, always a marked feature of the disease, is now 
very pitiable. The tongue lies in the bottom of the mouth utterly 
devoid of power, so that the patient cannot protrude it, and it becomes 
useless for all purposes. If the posterior wall of the pharynx be irritated, 
there is none of the reflex response which is so marked in the normal 
state, but only pain is produced. Such was the condition of affairs noticed 
in one of Dr. Dowse's patients. 

The epiglottis does not cover the larynx; and there is a tendency to 
choking from the accidental introduction of food, so that eating becomes 
a dangerous undertaking. The voice grows very weak, and the sufferer 
can no longer even make the almost unintelligible sounds which charac- 
terized the early stages of his disease. 

His breathing now becomes very irregular, his inspirations are quite 
slow and shallow, and he sinks from exhaustion due to insufficient nourish- 
ment and becomes a mere wreck, dragging himself about, and looking for- 
ward to death as something which alone is to bring relict". As the pneumo- 
gastric becomes more and more involved, the respiration undergoes changes 
which result in asphyxia. 

For some time before the end. his Bufferings grow intense. Mucus 
collects in the bronchi, which lie is unable to remove by coughing, and 
be -it- in his chair with a feeling of greater security than when lying 



1 Sometimes the bolus of food finds its way into the larynx and sutl'ocat s the 

patient. 

99 



338 BULBAR DISEASES. 

down, for in the supine position the saliva finds its way into the larynx, 
and produces suffocation. Loss of consciousness or mental impairment 
is never a Bymptom of the disease unless it be of the complicated form. 

The following interesting ease was reported recently by Dr. A. H. 
Smith. 1 of this city : — 

The Bubject was a clergyman, aged sixty-one years. About fifteen years 
ago. after prolonged and severe exercise of the voice in preaching, he be- 
came hoarse, and ultimately his voice failed so that he could speak only 
in a whisper. 

After the lapse of a year he gradually regained the use of the larynx, 
hut as he did so lie became sensible of an imperfection in his enunciation 
of certain syllables, especially those containing the letters p, t, dj s. etc. 
This difficulty has increased until now the power of uttering the labial 
and lingual sounds is almost entirely lost. 

Later a difficulty in swallowing was gradually developed, which has 
reached such a degree that only to arm fluids can be taken, and these with 
great care and hesitation, as they are apt to cause strangling, and to re- 
turn through the nose. Mucus accumulates in the fauces, which he has 
great difficulty in getting rid of, and which causes a sense of strangulation. 

He finds that the movements of the tongue are Aery much restricted, 
and he has not the full control of his lips. 

His sight, taste, and smell are as perfect as is usual in persons of his 
age. The sense of touch, even in the paralyzed parts, is not impaired. 

He feels much less distress when the weather is warm, and dreads the 
approach of each winter. 

Such is the account which the patient — a very intelligent man — gave 
of himself. As to the objective appearances, the patient moved slowly 
and feebly, but this was evidently the result of mere debility. The next 
notable thing at a cursory glance was the expression of his mouth. The 
orbicularis muscle was entirely paralyzed, permitting the lower lip to fall 
away from the upper, and to become partly everted. There was also 
relaxation and eversion of the upper lip from the same cause. The leva- 
ton- menti and the depressores ang. oris were not involved in the para- 
lysis, and by their aid the patient was able to bring the lips into contact ; 
but when so approximated they projected forward, leaving a spa.ee be- 
tween them and the teeth, and giving a very peculiar expression to the 
face. 

When the mouth was opened the movements of the tongue were ob- 
served to be \w\ slew and very much restricted. The lip could not be 
turned upward to touch the roof of the mouth, nor backward beyond the 
bicuspid teeth. The tongue was not notably changed in shape or size. 

All the muscle8 of the soft palate, including the palatn-pharvngi and 

palato-glossi, were paralyzed, so that when the head was thrown back- 
ward the relaxed velum fell of its own weight against the posterior wall 
of the pharynx. The finger carried into the fauces produced scarcely any 
Local reflex action, showing that the constrictors were complicated; but 

Sensation Was perfect, and the reflex action of the stomach seemed unim- 
paired, efforts ;ii vomiting being readily excited. 
There was a very profuse secretion of mucus from the Larynx and 



1 Med. Record, Nov. 24, L877. 



BULBAR PARALYSIS. 339 

pharynx, which was gotten rid of with the utmosl difficulty. There being 
perfect inability to contract the cavity of the pharynx, the air which was 
forced from the larynx in the act of hawking escaped into a great loose 

bag, instead of into a narrow, firm passage, and thus it failed to drive the 
mucus before it. The paralysis of the soft palate added to the difficulty, 
for when by great labor a, portion of mucus was coughed up into tin- hack 
part of the mouth, the non-closure of the isthmus faucium permitted it to 
fall back again upon the larynx. 

Examination with the mirror showed that the laryngeal muscles re- 
tained their activity, and the cords, with the exception of slight hyperae- 
mia, were normal. The respiratory muscles were as yet unimpaired. 

In this case it is not probable that the loss of voice, which occurred in 
the early stage of the disease, was owing to a central lesion, since, after a 
year had passed, the larynx gradually regained its power. Moreover, 
laryngeal paralysis of bulbar origin does not usually occur in this associa- 
tion until after the paralysis of the lips, tongue, and soft palate ha- become 
well-marked. It is more than probable that the aphonia was the result of 
a catarrhal affection, and that if life continues long enough there will be 
a return, but this time from advancing changes in the medulla. 

The greater ease in swallowing war/// fluids is characteristic of dyspha- 
gia from almost any cause. Thus it is observed in both organic and spas- 
modic stricture of the oesophagus, and also when dysphagia results from 
the pressure of a tumor. 

Dowse 1 considers the disease to be either progressive, stationary, or re- 
trogressive, and if it were not for the single case of the last variety, which he 
publishes, I should not be prepared to accept the two latter divisions. 
This he calls reflex bulbar paralysis. His patient, a woman aged .V.). 
suffered from Bright's disease and inflammation of the maxillary and 
parotid glands. After her recovery from the last-mentioned condition, 
there was paralysis of the hypoglossal, facial, and spinal accessory nerves, 
as well as the third division of the fifth. The vocal cords acted feebly, 
and she could scarce speak in a whisper, being able to pronounce only the 
Unguals /• and s, and could not protrude her tongue; food lodged in the 
cheeks: sali va dribbled from the mouth; she was unable to blow out a 
candle, while deglutition was interfered with to some extent. Strange i<> 
say, there has been improvement. It would be well, however, if Dr. 
Dowse had allowed a longer time to elapse before coming to a conclusion 
in regard to the retrogressive character of the disease in this instance, for 
the parotitis may have been simply a coincidence. I am inclined to think 
that tin.' history of any genuine ca.se thus far reported has shown a ten- 
dency to progressive decline which, though delayed in some instances, has 
nevertheless steadily advanced to a fatal termination. 

Causes The disease is one of middle age. and attacks men more 

often than women. It is usually the result of syphilis, ami sometimes fol- 
lows expo-ure and mental worry. Dowse Considers the causes of the 
peripheral symptoms to be the following: — 

1 lb-it. Med. Journ., N<>\ . 1 1. 1876, p. 615. 



340 BULBAR DISEASES. 

♦ Direct. 

1. Progressive interstitial neuritis. 

2. Thrombosis. 

3. Hemorrhage. ") 

4. Morbid growths, r Rare. 
.'). Vascular spasm. ) 

Indirect. 

1. Keflex action from peripheral irritation. 

2. Inhibition from shock to central cerebral ganglia. 

Morbid Anatomy and Pathology Trousseau's autopsies re- 
vealed induration of the medulla, atrophy of the roots of the hypoglossal 
ami spinal accessory nerves, thickening, and gray discoloration of the dura 
mater on a level with the medulla, which extended as far down as the 
POOtS of the fourth cervical pair. "This thickening was due to a consid- 
erable increase in the amount of fibres of connective and fibro-elastic tis- 
sue, and seemed to result from a chronic congestive process, as shown by 
the great number of capillaries and of deposits of luvmatin external to 
them. The motor nerve-roots of many cervical nerves were found thinner 
than they should be from disappearance of nerve-tubes. The fifth and 
glossopharyngeal nerve-roots were healthy, and the muscular tissue of the 
paralyzed parts was found to be normal." 

Dumenil published a ease which was probably progressive atrophy, but 
some <>f the symptoms were those of the disea.se under consideration. In 
this case there was extensive atrophy of the roots of the hypoglossal. 
pneumogastric, and fecial nerves, as well as a, great many other changes. 

Fox 1 considers an absolute or partial disappearance of the nerve-tubes, 
with preservation of the ueurilemma at the uerve-roots, to be a. constant 
Lesion; and Wilks' 3 found the roots of the hypoglossal and spinal accessory 
nerves had undergone atrophy, and become reduced to "little thin 
gelatinous threads." 

Sclerosis may occasionally involve the medulla, and product 1 symptoms 
characteristic of Loss of function in the uerves to which I have alluded. 

Charcot? give8, among other cases, one that involved the medulla ox- 
tensively. A patient of his presented, besides the ordinary symptefms of 
disseminated sclerosis, three months afterward, evidences of invasion of 
the pneumogastric and hypoglossal nerve-roots. There were dyspnoea and 
dysphagia. The patient was obliged to eat more slowly; and oftentimes 

the food Was regurgitated through the no>lii!<. Death followed in about 

Bis weeks afterwards, and was preceded by asphyxia. 

The autopsj revealed the following slate of the nervous centres: A 
section made one centimetre below the protuberance, at the point of origin 



1 Op. <•'■(.. p. 284. 2 Guy's Heap. Rep., \<»l. \\. 

Lecooa mr Lea maladies du systeme aerveux, Paris, 1872 7:i. Premiere 
partie, p. 29 i- 



BULBAR PARALYSIS. 341 

of the trigeminus, disclosed a point of sclerosis. Other transverse -■ ctiona 
were made at the smaller part of the olivary bodies, and a sclerosed patch 
was discovered. Another patch was seen at the root of the pneumogastric. 
Examination by the microscope revealed a number of broken nerve-tubes 
and broken-down cells at the nuclei of the hypoglossal, and traces of irri- 
tation in the white substance of Schwann in the pneumogastric fibres. 
The pharynx and larynx were healthy. 

The observations of Lockhart Clarke have shown the intimate relation- 
ship of the nuclei of the important cranial nerves which become affected 
in bulbar paralysis. There is a set of nerve-cells common to these nerves, 
and disease of the nuclei of one nerve is very likely to extend to other- of 
the group, so that ultimately there is a general invasion, which is bilateral 
and never one-sided. 

The destructive process is probably myelitis, as Leyden ha- suggested, 
and disappearance of the motor-cells is the direct cause of the paralysis. 

It is a curious fact that tlie sixth nerve invariably escapes when we 
remember that it arises from a common nucleus with the seventh, as 
demonstrated by Lockhart Clarke; and Stilling. In regard to the partial 
paralysis of the facial as an early symptom, and the subsequent increase 
in the area paralyzed, we must remember Romberg's statement that in 
organic brain-disease the entire distribution is not affected, but that the 
fibres involved are those that supply the muscles of the upper lip and alae 
of the nose; and this is an important point in the diagnosis from peripheral 
paralysis; and Dowse, calls to mind the fact that bilateral paralysis of the 
muscles supplied by the facial is connected with lesion at the root of the 
nerve. 

The aphonia may result, according to Dumenil, either from paralysis 
of the thoracic muscles, or of those of the larynx. The ptyalism I am 
inclined to ascribe, in the later stages, to paralysis of the chorda tympani, 
but agree with Hammond that the accumulation of saliva, in the first stage 
is due more to the patient's inability to swallow it than to anything else. 
Respiratory troubles may be due to paralysis of the pneumogastric and 
its motor, the spinal accessory. 

Dowse has divided the disease into three stages as regards the difficulty 
of swallowing, the first of which is connected witli paralysis of tin' hypo- 
glossal; the second with paralysis of the motor branches of the glosso- 
pharyngeal; and the third with paralysis of the spinal accessory. 

Voisin, in speaking of the alterations in speech, defines them into stut- 
tering, drawling, hesitation, jabbering, stammering, and quavering. The 
first three are due to lesions of the nerve-tracts which pass from the anterior 
cortex to the medulla oblongata, and which traverse the corpora Striata, 
crura cerebri, and pons, and are connected with disturbances of will. 
The other three have no such origin, but depend upon incoordination of 

the muscles supplied by the hypoglossal, facial, and glossopharyngeal 

ner\ es. 

Diagnosis — Facial palsy, general paralysis of the insane, progressive 



342 BULBAR DISEASES. 

muscular atrophy and diphtheritic paralysis may suggest themselves, and 
some are rather difficult to exclude: — 

1. Facial palsy may be suggested, but as tliis disease is of sudden origin, 
and affects other muscles than those about the mouth, there need be no 
reason to confound it with bulbar paralysis. 

2. The early symptoms of general paralysis of the insane somewhat 
resemble the initial symptoms of the disease of which we are speaking. 
Then- is tremor of the tongue, however, in addition to the embarrassment 
of speech ; and subsequent psychical symptoms make the diagnosis clear. 

3. Progressive muscular atrophy rarely attacks the tongue primarily, 
and only one case has been reported (by Charcot) where there were any 
bulbar Bymptoms. The subsequent atrophy of other muscles will dispel 
any doubts the observer may have. The affection of the medulla is ordi- 
narily a final result of the extension of the central disease in progressive 
muscular atrophy. 

4. Diphtheritic paralysis is symptomatized by initial paresis of the mus- 
cles of the pharynx, and the tongue is seldom involved. A previous his- 
tory of diphtheria will confirm the cause of the paralysis, should there be 
a suspicion. 

Prognosis As I have said, Dowse believes that there are forms of 

the disease which may be cured, viz., the stationary and the retrogress! re. 
1 cannot believe that, when once affected by inflammatory disease, such 
extensive alteration and such decided' symptoms as he mentions can ever 
be removed. 

The histories of the cases reported by the several observers already 
mentioned certainly offer a gloomy prospect and little encouragement for 
th<- victim. 'I'hc only case reported ;i- actually cured was that of ( Iheadle, 1 
and from the pain, visual trouble, and unilateral paralysis, it is improbable 
that the case was one of genuine bulbai* paralysis. 

Treatment Nothing lias been done which has resulted in any 

decided improvement. Hammond- relates a case which was somewhat 
benefited by faradization, but I am sorry to Bay that electricity did do good 
in the one case I have treated. Dowse recommends cod-liver oil, iron, 
and phosphorus. 



1 Glosso-labio-laryngeal Paralysis, St. George's Hosp, Reports, vol. v., 1871, 



p. 123, 
2 Op. oit., p, 518. 



CEREBROSPINAL MENINGITIS. 343 



CHAPTEE XIII. 

CEREBROSPINAL DISEASES. 

CEREBRO-SPINAL MENINGITIS. 

Synonyms Spotted fever; Me"ningite foudroyante; Head pleu- 
risy; Myelitis petechialis ; Cerebral or Cerebro-spinal typhus; Alenin- 
gite cerebro-spinale ; Fivere cerebro-spinale, etc. 

Definition A disease characterized by inflammation of the meninges 

of the brain and cord, symptomatized by pain, tetanic spasms, and herpetic 
eruptions, and occurring in an epidemic form. 

This most terrible disease has of late years received a great deal of atten- 
tion at the hands of German and French writers. Niemeyer 3 was one of 
the first of the former to direct attention to the disease ; while in France 
Broussais and others contributed extensively to the literature of the sub- 
ject. There is no doubt as to the antiquity of the disease, for among tin- 
writings of Hippocrates a nearly perfect description of the malady is to be 
found. In our own country the epidemic character of the affection was 
noted by several of the older authors, among them North 2 (1811), Gallup 9 
(1815), and Minor* (1823), and their contemporaries. Outbreaks occurred 
at Medfield, Mass., Litchfield Co., Conn., and at various points in the 
Eastern and Middle States during the early part of the present century. 
Clymer, 5 Jones, 6 and others have since written exhaustively on the subject. 

Cerebro-spinal meningitis is certainly an irregular disease; it is not 
contagious, and it is influenced seemingly in no way by climate, origin, or 
soil. 

Symptoms The appearance of symptoms is usually quite sudden. 

and their course is remarkably rapid and ordinarily tends to a fatal termi- 
nation. In exceptional cases pain in the back, headache, vomiting, or 
malaise may constitute a premonitory stage, which lasts a few hours ; but 
usually there is no such delay. A severe rigor, an attack of vomiting 
which is followed by headache of an intense description, and an elevation 
in pulse and temperature mark the commencement of the trouble. The 
child may present these symptoms, ami in addition another Bymptom 

1 Treatise referred to in Niemeyer' s Text-Book of Prac. Med., vol. ii. p. 218. 

2 Treatise en a Malignant Epidemic, etc.. 1811. 

3 Sketches of Epidemical Diseases, etc., 1815. 

4 Essays en Fevers and other Medical Subjects, Middleton, Conn., 1828. 

8 Aitken's Science and Practice of Medicine, pp. 492-505, 3d Amcr. edit. 

6 Med. and Surg. Memoirs, pp. U 2-507. 



344 CEREBROSPINAL DISEASES. 

which is invariably pathognomonic. The head is drawn back/cards and 
downwards, and the muscles at the back of the neck are rigidly con- 
tracted. At the same time the pupils are contracted. The child moans 
constantly, and is restless; this is an early symptom, and may appear at 
the end of twenty-four hours, and be the first to attract our attention. 

The pulse is now quite rapid, and may beat 100 to 120 per minute. 
The pain meanwhile increases, and affects the head as well as the entire 
length of the spine, and is increased by pressure. Just as in other forms 
of meningitis, the movements made bythe patient aggravate his suffering, 
and lie usually strives to keep quiet. He is conscious for the first two or 
three days should he live so long, but at the end of this time he loses his 
intelligence after first growing delirious. The pulse, temperature, and 
respiration are increased. The former sometimes beats 130 per minute, 
while the thermometer may indicate an advance to 104°, but it usually 
remains at about 100°. At an early period crops of herpes appear upon 
the face and limits, and the skin is hyperaesthetic, and the patient cannot 
hear handling. After the first ninety-six hours the convulsions succeed 
the primary rigidity. Opisthotonos or other tetanic contractions make their 
appearance. Stupor follows, and he dies in a condition of coma; and 
according to Niemeyer death takes place with symptoms of oidenia of 
tic- lungs. The bowels are constipated during the entire disease, and 
during the later stages the patient has involuntary discharges of urine. 

The above description is of an ordinary case. There are great varia- 
tions, and either death may take place in a few hours, or there may be a 
tardy convalescence accompanied by structural changes of a very serious 
nature. The course of the disease may open with chill followed by rapid 
Convulsions and coma, when the patient may die in less than twenty-four 
hours. 

In other cases, after the subsidence of the acute symptoms, which may 
last for a week or two, convalescence takes place, attended by headache 
and muscular contractions, which continue for some time. Deafness very 
often results; and I have several times met with total loss of vision, and 
paralysis of some of the facial muscles. In one case brought to me from 
the interior of tic State, there was rigid contraction of the muscles at the 
back of the neck; and in another, seen with Dr. F. II. Rankin, now of 
Newport, besides ptosis and paralysis of the pharynx, there was an otor- 
rhea, with extensive middle-ear disease. This patient was quite an im- 
becile, intellectual impairment lasting after the subsidence of the acute 
stages. One of these chronic cases has been under observation for several 
years, but I have been unable to effect more than trifling improvement. 

Causes. — Epidemic cerebro-spinal meningitis seems to be much more 
common during ••old weather, mid is much oftener met with during infancy 
than ;ii .-Li in other period of life. Adults are no1 exempt ; but the disease 
prefers the young. It i- ;i disease, like typhus, which usually attacks 
the poor; and bad ventilation and insufficient food seem to pre] tare the 

way f<»r epidemic-. In the city of New York, the first outbreak of the 

disease appeared in 1866; and subsided, i<» reappear, February, L872. 



CEREBROSPINAL MENINGITIS. 345 

In the sparsely settled wards of the city (the 19th, 20.th, 22d), where 
building was going on and fresh earth turned up, it seemed to prevail. 
There were 45 fatal eases during the winter quarter in these ward-, while 
the entire number of deaths in New York during the same period from 
this cause was 108. During; the spring quarter there were J'.'2 deaths, 1 18 
being in these wards. It subsided in the spring of 1«7.'5, hut reappeared 
during- the autumn of that year. It would seem, from these statistics, that 
overcrowding had but little to do with the disease, bu1 thai had drainage 
(this portion of the city being imperfectly drained) had undoubtedly Borne 
influence. 

Morbid Anatomy The meninges of the brain show evidences of 

intense hyperemia, the sinuses being distended with blood which Blowly 
coagulates, and the dura mater is the seat of ecchymotic spots. There is 
usually a sero-purulent exudation beneath the arachnoid, and this is found 
at the base of the brain as well as in the ventricles. It may be recognized, 
also, in the different fissures and sulci. The spinal meninges are the Beat 
of the same exudation, it being found beneath the dura, or between the 
arachnoid and the pia mater. All of the spinal membranes are vascular, and 
opaque in spots. The exudation appears to be confined to the posterior 
parts of the cord ; and usually, when infiltration in the cord has taken place, 
small elevations may he observed beneath the pia mater. According t<> 
the German pathologists, the cervical portion of the pia mater is not com- 
monly the seat of exudation. The membranes are often adherent, and 
patches of false membrane are visible, so that sometimes the sub-cerebral 
nerve-trunks are bound together and connected by bridges of organized 
lymph. The nervous tissue proper is extensively softened in rare cases, 
especially if the inflammatory action has been at all severe. Spots of 
localized softening are, however, not uncommonly observed, 

Diagnosis Cerehro-spinal meningitis sometimes resembles certain 

irregular forms of malignant malarial fever, on account of intermissions in 
the febrile state. This is the case more especially during convalescence, 
when the affection assumes a periodica] character. The chill in cerebro- 
spinal meningitis is not so marked as in the true malarial affection, and 
contractions of tin; muscles are rare in any form of malarial trouble. The 
other points of difference may he thus summed up: — 

CEREBRO-SPINAL MENINGITIS. CONGESTIVE PERNU [01 - MAI A. RIAL 

ri \ I i;. 

Bowels constipated. Not usually so. 

Pulse ;iikI temperature do not suffer Both subject to great variations, 

rapid variations. feeble and irregular (Jones). 

Temperature does not undergo peri- Temperature undergoes decided peri- 
odical changes. odical changes, 

Face flushed; eruption. Complexion sallow. 

Delirium and coma not affected by All symptoms modified usually by 

large doses of quinine. negative treatment with quinine. 

Increase of tihrine. and rapid coagu- 
lation of Mood when drawn. 



346 CEREBRO-SPINAL DISEASES. 

A malignant typhus, or a masked variola, might counterfeit cerebro- 
spinal meningitis ; or, on the other hand, acro-narcotic poisoning might 
simulate the affection. The absence of tetanic spasms of the post-cervical 
muscles i>. however, so prominent a symptom that when it is present the 
probability of cerebro-spinal meningitis is considerable. 

Prognosis This disease, like other forms of meningitis, has a bad 

character. Death is generally the rule, recovery the exception. In the 
city of New York the total number of deaths from all causes was 29,084: 
during the twelve months ending Dec. 31, 1873. Of these, 9503 were 
placed under the head of zymotic diseases ; and the number of deaths due 
in cerebro-spinal meningitis was 290. Of these, G9 were under one year, 
and 164 under five years. Very few cases were over thirty. In the ma- 
jority of cases the disease runs its course in from 4 to 20 days. In fatal 
cases death occurs generally before the 12th day, 

Treatment. — In regard to treatment, little can be said that will 
be encouraging. The ordinary antiphlogistic treatment, consisting of 
abstraction of blood by leeches applied to the mastoid processes, and 
bladders of ice to the head, and large doses of calomel, according to 
some observers, have cut short the disease, especially when these reme- 
dies were used at its commencement. The almost wonderful results 
thai have followed the use of ergot in large doses suggest this remedy 
to us, and I have no doubt that it will prove to be very efficacious. 
Ziemssen recommends morphine, and has never observed any unpleasant 
effects following its employment. 



CEREBRO-SPINAL SCLEROSIS. 

Synonyms Sclerose en plaques^ disse'minees (Charcot and Bourne- 

ville) ; Insular sclerosis (Moxon). 

For a long time this disease was mistaken for paralysis agitans ( Parkin- 
son's disease), chorea, and other neuroses; and even after it had been 
shown to be a separate neurosis a certain amount of confusion existed in 

regard to its nomenclature and its position among the scleroses. Charcot 
and Moxon 1 an- to be thanked especially for their successful efforts to give 
it a distinct character. 

Symptoms We may <li\i<le the progress of the disease into three 

stages. 

]\/ Stage The firsl symptom, which is common to several other neu- 
roses, is gradual Loss of power in the lower limbs, which, by itself, does 

not attract attention to the grave nature ol the disease in its incipieiicv. 

With tin- weakness there is no atrophy and no Loss of sensation, while 
reflex excitability is either normal or only Blightly increased. The rec- 

t iimi is in , i affected, nor is the bladder, and there is simply a. paresis which 
1 ; i - 1 - lor ;i variable tine-, perhaps lor two or three months, or for a much 



1 Eight cases of insular sclerosis <>!' the braiD and spinal cord, l>\ W. .Moxon, 
.M.l».. 1 1 Hospital Reports, rol, xx., L875. 






CEREBROSPINAL SCLEROSIS. 347 

longer period. The partially paralyzed limbs become agitated by tremors, 
which are seen best when the patient takes some constrained position, or 

attempts to walk a straight line. He may have the gait of an ataxic, but 
generally the walk is more like that of a general paralytic, being charac- 
terized by weakness of the extremities. As the disease invades a higher 
portion of the cord, we will find tremor of the upper Limbs and paralysis 
of the cranial nerves, indicated by symptoms I shall describe in speaking 
of the descending variety. I may allude, however, to a particular de- 
fect in articulation, the patient being unable to pronounce some of the 
labial consonants. 

2d Stage Rigidity of the limbs supervenes, with various contractures 

of a spasmodic character, and exaggeration of tin; tremor. One of my 
patients died in her bed with her knees drawn up to her chin, her legs 
flexed on the thighs, and her arms drawn closely to her chest. It required 
quite violent exertion for me to extend the limbs, and the tremor was 
markedly aggravated when I did so. Electro-muscular irritability is next 
greatly increased, and reflex excitability heightened. Epileptiform at- 
tacks may now appear, as well as apoplectiform, and death may occur at 
this period from the invasion of some cerebral vessel and consequent cere- 
bral hemorrhage. 

3d Stage This stage is marked by rapid decline of the patient's 

strength. Incontinence of urine and feces, bedsores, and dementia follow, 
and, after other evidences of gradual wasting away, death may end the scene. 

The course of this form is : First, paresis of lower extremities and 
tremor; second, contraction, and aggravation of tremor; third, general 
dissolution. 

1st Stage of Descending Form : This is the condition of affairs when 
the cord is attacked secondarily. When the disease begins in the brain, 
the early symptoms may be headache, convulsions, vertigo, or. what is 
more common, paralysis of some of the cranial nerves ; there may be 
ptosis, strabismus, loss of hearing, and facial paralysis, or trouble- of 
speech and embarrassment in swallowing. The important symptom next 
in advance is the appearance of tremor, which is first seen in the tongue, 
whi,ch, when protruded, trembles visibly; or it may affect the lips, as may 
be noticed when the patient, speaks. The eyeballs oscillate (nystagmus . 
and the head may become agitated, and afterwards the upper extremities. 
A peculiarity characteristic of all forms of sclerosis is not absent here, 
viz., the aggravation of tremor by voluntary efforts made to control it, 
and its diminution during rest. If the individual attempts any complex 
action, he is utterly unable to complete it properly, for the movements 

increase until muscular control is entirely lost. I have alluded to the l<>-t 

Sense of location, which is also seen in advanced locomotor ataxia, and I 
may state that it is also a symptom of this form of Sclerosis. 

2d Stage: The limb- lose their power to a great extent as the disease 

advances, and permanent contractures of the upper and lower limbs, which 

by this time are affected, render the patient very uncomfortable. His 
forearms may be flexed, and the fingers are doubled up, as is the case in 



348 CEREBROSPINAL DISEASES. 

uncomplicated lateral sclerosis. The thighs are even flexed on the pelvis, 
and the legs may he as well. The knees are approximated quite forcibly, 
and it is often difficult to separate them. This stage may last for several 
years. 

3d Stage : Meanwhile the tremor has continued, and increased in vio- 
lence; but it may sometimes be stopped by flexing the great toe, just as 
Brown-Sequard has shown may he done in epilepsy. The bladder and 
rectum are now involved, and the patient sutlers terribly from cystitis, 
and is prostrated by diarrhoea. Bedsores form, and he gradually 
sinks into a state which invariably lias a fatal termination. In both 
varieties there is great difficulty in articulation, and disturbance of 
function in those organs supplied by the lower cranial nerves. The lower 
lip falls, and there is dribbling of saliva, while food often remains in the 
mouth wedged between the teeth and between the gums and cheek, and 
liquids find their way through the nostrils. Beyond slight irritability and 
restlessness, there are usually no mental symptoms at the outset, or until 
the fixed stage, when sometimes there is intellectual as well as physical 
decay ; but this is not the rule. A case which seems to be of great interest, 
because of the atrophy of the upper limbs, came under . my notice two 
years ago. 

K. ^Y.. aged o7, salesman, no family history of nervous trouble. Father 
and mother alive; nothing to account for his present condition. Five 
years ago he was employed in a drygoods store, and his attention was 
called to a slight weakness in his thumb and forefinger of the right hand 
when he used his scissors. There was subsequent tremor, which annoyed 
him excessively, and which subsequently became quite general. About the 
same time he was subject to very severe headache, vertigo, and sometimes 
vomiting. The tremor meanwhile increased, and it became so violent when 
he attempted to execute some fatiguing act that he was forced to desist. 
lie next noticed that his vision was beginning to be impaired, that he saw 
double, or that ••mist floated before his v\^^. ,, The trembling continued, 
and when he came to me I found his condition to be as follows: The pa- 
tient is n tall man, of decidedly nervous temperament, quite feeble and 
emaciated, and \ rvy much depressed. Both arms are convulsed by t pernors, 

but especially the right. The biceps and the extensors of the hand are much 
atrophied, and there is great loss of power. lie tells me that the tremor 
has been much more violent than it is now. The sensibility of the cula- 

noous Burface is rather lowered, and there is a certain amount of analgesia, 

so that pins may be run into the dorsal aspect of the forearm without pro- 
ducing pain. He was able to press the fluid in the dynamometer up to 
7. -Ml with the right, and to 17 with the left. There is still headache at, 

times, and some dizziness. The left eyelid seems to cover the eyeball 

more fully than the right, and the muscles of the left side of the face were 

trembling quite violently. When I told him to whistle, his lips trembled 
mi much that he could not do boj and when I requested him to repeat the 

(ituttarj 

line "lieu Battle was a g^ldfer hold." In- did ii as follows: "Me-e-n 

(■tow) (i-x|.!...i..n . (explosion)! 

m-m-m-etta was n - <» o g a m-mold." Mi- articulation was quite defec- 

1 The intonation wu rerj much like whal we would expect to find in "cleft 
palat 



CEREBROSPINAL SCLEROSIS. 349 

tive, and I had great difficulty in understanding him. His tongue trem- 
bled, and his lower lip seemed to sag and fall forwards, and he was obliged 
to wipe his mouth quite constantly, as there was a considerable escape of 

saliva. When I told him to hold his head in such a position that 1 might 
examine his eye with the ophthalmoscope, it shook to a great degree, and I 
had great difficulty in illuminating the retina. He says this i- recent, and 
that his head was not affected by tremor until a month or two ago. His 
mind is clear, and his memory unimpaired. I have seen him hut once, 
and there has been no advance in his condition. 

The following case is reported by Bourneville : — l 

Rosine Spitale, 20 years old. At 17 years of age she was suddenly 
affected (after crossing a small stream and becoming chilled) with loss of 
power, first in the right lower extremity, and then in the left, and some 
time after the hands began to tremble. At 18 there was sonic subsequent 
improvement, but it was very slight. Soon afterwards menstruation 
ceased, and some time after this the symptoms reappeared. Hemiplegia 
occurred without loss of consciousness or convulsions, and the tongue and 
eyes were involved. The disturbances of sensation were moderate; there 
was a certain amount of numbness in the lower limbs, and a sense of clum- 
siness of the tongue, with difficulty in articulation, and some diminution 
of mental power. At the beginning of 1 853 the patient was well nourished. 
.V half grain of strychnine daily has produced an amendment for ten or 
twelve days. Electrization produced movements in the lower limbs, and 
increased the trembling in the upper extremities. In the course of the 
month the paresis of the inferior extremities was nearly complete, the 
trembling of the eyes with dilatation of the pupils is quite pronounced, 
and the patient has become very stupid. 

January, 1854. The hands tremble less than they did. There are in- 
voluntary discharges of urine. Ergot 5'j P er day nas been used for 
several months. It acted once upon the sphincters, and seemed to improve 
the weakness of the limbs, for several movements were possible. 

Spring, 1854. Bedsore on sacrum. 

Septeutber. In a state of decline; the bedsore has extended very rap- 
idly; pain in the head; pulse 13G. 

October. Repeated rigors; sensibility of the inferior limbs returned; 
feebleness of the extensors of the back ; scoliosis towards the right: the 
trembling in the extremities persists. 

November 1. Death, preceded by involvement of the muscles of the 
pharynx. 

Autopsy — The gray matter is hard; the nervous substance in the 
neighborhood of the lateral ventricles and that of the protuberance were 
hard. We found gray nodules superficial and deep. The white substance 
had become hard in spot-. Beneath the microscope the indurated nodule- 

(white) consisted of a fibrous, mass-like, connective tissue; the elements 

of the nervous matter had almost entirely disappeared; and the white 
nodules wire pressed beneath the surface of the cut. The spinal cord 
was indurated. The great vessels and viscera were healthy. 

Dr. Geo. S. Gerhard 8 has presented the following interesting case of this 
disease : — 

1 La Sclerose, etc. Park Is*;:', p. 92. 

2 Philadelphia Medical Times, November 11, 187 



350 CEREBRO-SPINAL DISEASES. 

Samuel A., set. o7, a native of Ireland, and a blacksmith by trade, 
wa9 admitted into the out-patient department of the Infirmary for Nervous 
Diseases on September 17, L876, and gave the following history. His 
health had always been good until about seven years ago, when, after no 
known cause, he began to lose power in the legs. One year after this his 
arms grew weak, and lie then observed for the first time that any move- 
ment of the upper or lower extremities was accompanied by tremor. At a 
somewhat later period his speech became affected. The weakness of his 
limbs and the trembling gradually increased, until finally, about four years 
ag<». he was obliged to give up work. 

On admission there is decided loss of power in the upper and lower 
extremities, and upon his attempting to use either, a large and jerky tremor 
is developed, lie walks with the assistance of a cane, but his movements 
air -low. and his feet clear the ground with much difficulty. His grip, 
particularly that of the right hand, is feeble, squeezing the dynamometer 
with the former to 100° and with the latter to 110°. In the upper extremi- 
ties tin' trembling is especially well shown during the performance of an 
acl requiring some little time for its execution, such as lifting a glass of 
water to the mouth. The tremor also involves the muscles of the head 
and trunk, but it ceases entirely when the patient is in a state of absolute 
repose. There is no muscular wasting, no loss of electrical response, and 
no disturbance of sensibility. 

His mental faculties are decidedly impaired, and his speech is thick 
and deliberate, there being a. decided interval between each word. His 
eyesight is poor, and examination of the fundus reveals commencing 
atrophic changes, as shown by attenuation of the vessels and a general 
pallor of the optic disk ; there is also slight nystagmus. The unsteadiness 
of gait and the tremor are not increased by closure of the eyea. His urine 
is in all respects normal, and he has no loss of control over the bladder or 
bowels. 

Causes. — Jaccoud is of the opinion that sclerosis occurs as a disease 
of childhood or adult life up to 45 ye;ws, and thai there is nothing to indi- 
cate the special liability of either sex ; while Charcot considers it a dis- 
ease which LS much more common among females than males, and that it 
rarely appears after 40. Of six cases I have recorded their respective ages 
were is. 26, •"'•"'. 37, 41, 46; four were males and two females. Of 
eighteen cases collected by Bourneville fifteen were women and three men. 
Ill three of bhe8e the disease began between 36 and 1<>, three between 30 
and 35, and the others between L5 and 30. Of Hammond's cases, eleven 
were men and two women. Very little is known in regard to the etiology 

of sclerosis; lot " moist cold," emotional excitement, and venereal excesses 

are spoken of by the different Continental writers as causes. 

Bourneville found thai the greater number of his cases died between 85 
and 50, and thai the disease appeared in mosl instances between the ages 
of "it. and 35. Iii one of my patients the disease began al the 5th year, 

in another :il about the L8th year, and in the third and fourth al 32, and 

in the fifth and Bixth between 35 ami in. 
Morbid Anatomy and Pathology.— I have spoken in another 

chapter about the UlOrbid appearances in BClerOSis, and nothing remains to 






ALCOHOLISM. 351 

be said in regard to this particular form. It is only a question of location 
that concerns us, and after death we will probably find patches of tissue 
scattered through the brain and cord. The antero-lateral columns seem 

to be invaded in nearly all cases, and this would appear probable from the 
contractures. 

Diagnosis In the ascending form it must be remembered thai the 

tremor follows the paresis, while the descending form is characterized by 
tremor as a primary affection, or at least before the muscular paresis of the 
extremities. Paralysis agitans may be confounded with the descending 
form of the advanced disease ; the tremor in the former disease is continu- 
ous, and is often not affected by quieting influence or sleep, but is not 
aggravated by efforts of the will. The early symptoms of this form may 
also point to progressive paralysis of the insane, and to intracranial tumors ; 
but the subsequent progress of the affection, the development of new symp- 
toms, and the common absence of neuro-retinitis, are sufficient to remove 
any doubts as to its true nature. 

Prognosis Invariably bad. 

Treatment I know of no remedy that can reconstruct a degenera- 
tion of nerve-tissue which consists in proliferation of connective-tissue 
cells, and nerve-tube disappearance. Nitrate of silver, chloride of gold, 
galvanism, bichloride of mercury, and chloride of barium have been all 
used. It seems that only one chance may exist — the possibility of syphilis. 
If this be present, it is probable that specific treatment will be successful. 
We are to improve the patient's general condition, and relieve his tremor 
either by conium or hyoscyamus, and make him as comfortable as possible. 

ALCOHOLISM. 

ACUTE — CHRONIC. 

Synonyms Ebrietas, Alcoholismus, Delirium tremens; Mania a 

potu, Alcoolisme; Trunksacht; Chronic alcoholic intoxication (Reynolds). 

Definition A disease of the nervous system resulting either through 

direct action of alcohol upon its tissues, or through impairment of other 
organs which fail to remove effete substances from the blood ; and symp- 
tomatized by mental aberration, and by various sensorial and [notorial 
phenomena, usually the result of lowered functional activity. 

The immoderate use of alcoholic beverages is usually followed by the 
mosl deplorable consequences. Sad to say. this condition is too familiar 
to need any extended description, as far as the appearance of tin 1 
patient is concerned; but there are other features of the disease that need 
earnest and careful study. 

The effects of alcohol upon the human being may he said to be physiolo- 
gical and pathological. The sensorial alterations are much more interest- 
ing than the motorial, and of these we will speak in detail. 

The imbibition of a moderate amount of alcohol, as we know, is usually 



352 CEREBRO- SPINAL DISEASES. 

followed by a general feeling of comfort, a certain degree of exhilaration. 
The individual is no longer absorbed in himself, lie is animated and gay, 
his ideas flow rapidly, and he becomes tilled with greater energy and en- 
durance. If the dose be increased, the mental functions become more 
active. II" is excited and demonstrative, and either violent and noisy, or 
tender and maudlin, according to the thoughts which have most engrossed 
hia attention, or through the influence of temperament. Incoherence of 
speech and confusion of ideas succeed the ordinary mental excitement, 
and this may be followed by a condition of stupor, the individual becom- 
ing perfectly unconscious of injury, and unmindful of either bruises or 
cuts, or even severe burns. He may stagger and fall, and lie in some ex- 
posed place regardless of the blaze of the sun, the Hies, and the noise. He 
has Anally become reduced to what Magnan 1 calls " la vie vegetative." He 
is " dead drunk." This deep alcoholic stupor may last for some time, and 
end the patient's career; or he may become maniacal instead, or present 
the condition described by Percy' 2 under the name d'ivresse convulsive, 
in which, with clonic convulsions, he grows furiously maniacal, grinding 
his teeth, and cursing and menacing those about him. The maniacal 
attacks are no doubt influenced to some degree by the character of the 
illusions and hallucinations. 

ACUTE ALCOHOLISM. 

Symptoms. — The continued use of alcohol in excess for a. week or 
two. such as occurs during an ordinary debauch, is very apt to lead to an 
attack of delirium tremens. This slate of acute alcoholism may also occur 
should the patient, who has drunk not necessarily to intoxication, but to 
a degree almost approaching it, be deprived of his drink. 

One of the earliest indications of this state of alcoholism is a troniu- 
lousness or " shakiness," which is quite marked in the early part of the 
day. and is connected with nausea and want of appetite. The patient is 
restless and irritable, sleeps poorly, ami presents an appearance of dejec- 
tion and sadness. His eyes are red and watery, and his skin is of a 
muddy color. His features are drawn and haggard, and he is a wretched 
object indeed. The gastric irritability may he so great as to prevent any 

retention of food, and the simplest forms of nourishment are ejected by 

the stomach. Constipation is obstinate, and the urine is passed in small 

quantities and Loaded with the urate-, go that a dense brick-dust precipi- 
tate i- found in the chamber. The attack is immediately preceded by 
great excitability, and l»\ illusions and hallucinations, which grow very 
marked a- the patienl becomes aoisy and violent. Magnan has graphi- 
cally described the differenl varieties of mental trouble. 'Hie patient may 
be sad and utterly dejected, lb- may imagine thai he ha- committed 



1 Recherche* sur les centres nerveux, p. liii. 

I onvulsive, Dictionnaire des Science- Medicales, i. sxvi., p, _'i!». 






ALCOHOLISM. 353 

some great crime; that he has been em atenced to death ; that he is being 
executed ; and these delusions may markedly influence the character of 
his outward expression. In nearly every case then- is some delusion of 
persecution of a horrible kind. The attack usually begins with hallucina- 
tions of a visual character, in which snakes and other reptiles, devils, 
imps, gnomes, and goblins terrify the patient. In one instance which I 
remember, he was tortured by devils who held lighted candles, and 
were about to set his clothes on fire; in another case the patient en- 
deavored to escape a tailing weight. The illusion- are always followed by 
hallucinations, and finally by delusions. The irritations of the organs of 
Bense are distorted so that the simplest and most common noise- become 1 
changed by the patient's disordered imagination into the most terrible 
sounds. The cry of the vendor in the street is likened to the despairing 
shriek of a lost soul. The stroke of the clock, a funeral bell, and the 
voices of those in the room are supposed to be the savage yells of a howl- 
ing mob. The objects which the patient sees are nearly always trans- 
formed into animals, which, controlled by no natural laws, run over the 
ceiling, or gallop through the air. Odors are reversed, and food is sup- 
posed to be poisoned. Animals run over the skin; sometimes they are 
rats or lizards ; and at others he may call attention to the torture inflicted 
by thousands of needles or cutting instruments. Maniacal outbursts are the 
common feature of the attack, the patient seeming to possess herculean 
strength, and it is sometimes necessary to have six or eight strong men to 
prevent him from throwing himself out of the window, or committing 
some deed of violence. He may remain in this condition for several 
days at a time, during which period he neither sleeps nor eats. His 
ey.- are bloodshot, and he sweats profusely. The pulse 1 is very rapid, 
Etmall, and irritable, and though the deep temperature may reach 102 c or 
103° F., the hands and feet are cold, and the palms and soles clammy. 

When recovery takes place, the first change for the better is sleep. 
The violent symptoms subside gradually in the reverse order of their 
appearance. He may awake, after fifteen or eighteen hours, irritable, 
but not much better; or there may be a lesser degree of excitement, 
more sleep, and gradual improvement. 

In other cases death follows, there being a subsidence of the violent 
delirium, which changes its character and become- muttering; when he 
relapses into a typhoid state, and gradually passes away. 

The tendency to the commission of deeds of violence is quite charac- 
teristic of acute alcoholism. Of 377 cases observed by Bouchereau and 
Magnair in the year 1^7<», twenty-four attempted to commit suicide, and 
nine attempt- at homicide were made. These cases were seen under 

1 The sphygmograph has been employed 1>\ Anstie in cases of delirium tre- 
mens, and the tracing obtained \er\ closely resembles that of the typhoid I 
and inflammation. It is of a marked dicrotic type. 

■ op. cit., p. 129. 
23 



354 CEREBROSPINAL DISEASES. 

restraint, but among the eases which occur outside of hospitals and asy- 
lum-, the number is far greater. 

CHRONIC ALCOHOLISM. 

Symptoms A much more grave condition of affairs follows the 

continued use of large quantities of alcohol, and no more hopeless disease 
exists than that of which we are about to speak. While in delirium tre- 
mens recovery may take place, followed by total reformation, without 
any serious damage to the nervous system, the more serious nerve-changes 
wrought by constant saturation can never be repaired, but tend to further 
ration and decay. 

Chronic alcoholism begins by a number of insidious alterations in the 
nervous substance, whereby its functional activity is embarrassed, and minor 
symptoms at first, and more grave ones afterwards, appear very gradually 
and progressively. 

The victim of chronic alcoholism may present the symptoms of tremor 
and loss of power of which I have before spoken. The tremor is rhyth- 
mical, and begins at first in the extremities, and afterwards involves the 
entire body. There seems to be an accompanying want of power, for he 
relaxes his hold upon any object he may grasp when his attention is 
diverted. II is morning dram involves an effort worthy of a better cause. 
He grasps the glass with both hands, fearing that he may spill even a single 
drop of the precious liquid, and carries it carefully to his mouth, clutching 
the rim of the glass between his teeth, oftentimes witli sufficient force to 
bite out a piece. The lower extremities become involved, and the patient 
sliutlles along in a clumsy manner, his feet being scarcely lifted from the 
ground. His dress becomes disorderly, and his habits are no longer char- 
acterized by neatness and tidiness. His facial muscles lose their play, and 
hi- countenance wears a wonderfully woebegone and sorrowful expression, 
lie wanders wretchedly from one grog-shop to another; eats sparingly, 
and rarely ever, unless his worn-out stomach is stimulated by a dram. He 

loses flesh, and his clothes hang to his withered limbs like the vestment of 

a scarecrow. This is but the firsl step in the advancing disease. Memory 
becomes weakened, and forgetting even laces and names, he drops one by 

One his old friends, and sits in loneliness for hours at a time. 

The mind is utterly sapped, and he is reduced to a state of dementia. 
Numerous grave changes ocean- in addition to these. Speech becomes thick 
and unintelligible. In the early stages there may be convulsions or attacks 
of delirium tremens; but one of the most striking and serious expressions of 
the disease is the occurrence of paralysis; and there may be hemiplegia or 

paralysis of B Local character, the third nerve becoming implicated and 

ptosis resulting. The subject of chronic alcoholism is generally anaesthetic, 

and this to a marked degpee. Not only is tactile sensibility impaired, so 

tii ;i t be ifl unable t<» determine the nature of even a rough object, but he is 
unaffected bj extremes of temperature. In one case which I can recall, this 

Wafl illustrated by tin- fact thai in silting before the lire he thrust his toot 






ALCOHOLISM. 355 

beneath the grate, and left it there for Borne time before his position was 
discovered by a member of the family. Hemi-anaesthesia 1 is spoken of by 

some writers, but it is an extremely rare feature of the disease, and is pro- 
bably a late symptom resulting from organic changes on one side of the 
brain. Hammond 3 alludes to the anaesthetic condition of the cornea, which 
is occasionally not affected in the least by the touch of the finger. 

Convulsive seizures of different kinds are occasional evidences of the 
serious effects of alcohol. These may vary from simple Bpasm to a variety 
of convulsion which closely resembles a marked epileptic paroxysm. In 
fact the diagnosis is oftentimes very difficult. What I have said about the 
mental condition in acute alcoholism may be now applied. The halluci- 
nations and lighter forms of sensory and mental aberration exist at different 
stages, but towards the end the condition is one of dementia of the most pro- 
found character, the patient being completely oblivious of the outside world, 
and of his duties to society. lie is morally irresponsible, and the crimes 
he may commit are motiveless and dictated only by a diseased mind. 

Causes — Chronic alcoholism follow- the steady use of large quantities 
of alcoholic liquors, but is rarely found among those who drink wine or 
malt liquor. The French, Italians, or Germans are, therefore, seldom 
affected in their own countries, especially outside of the large cities, where 
a very small amount of ardent spirits is taken. In England, Scotland. 
Ireland, and America the case is different, for in these countries there is 
no low-priced light beverage which takes the place of the wines and beet 
of the European Continent, which are drunk in preference to water. 
Without entering into the discussion of the effects of alcohol upon other 
organs of the body than those of the nervous system, it may be said that 
the condition known as alcoholism springs from a protracted use of large 
quantities of strong liquor, so that the nervous substance is deprived of its 
normal nutrition, the blood being charged with effete substances which 
should be eliminated by the kidneys, lungs, and skin. 

Delirium tremens is due generally to the direct action of a large quan- 
tity of alcohol, which produces overwhelming toxic effects : while chronic 
alcoholism implies a structural degeneration due to the continual action of 
the alcohol itself, and to the vitiated blood. 

Delirium tremens may occur either from a sudden cessation of indul- 
gence, or in the midst of a prolonged debauch, mosl commonly, however, 
the latter. In some persons elimination goes on 80 perfectly that large 
quantities of liquor may be taken and disposed of without any pro- 
found effect upon the nervous system being produced. These individuals 
may drink to a point much beyond moderation, and still Buffer no marked 
inconvenience, the alcohol seemingly affecting some other organ, which 
may be either the liver or kidneys, so that cirrhosis or degeneration of 
other kinds may take the place of the cerebral trouble in the beginning. 



1 Magnan considers that hemi-ansesthesia and general paralysis are quite com- 
men results of chronic alcoholism, op. cit., p. 134. 
: Diseases of the Nervous System, p. 850. 



356 CEREBROSPINAL DISEASES. 

Males are much more often affected than females, as the statistics of 



Magnan show : — 




Acute alcoholism (D. T.) 


f 1870 
1 1871 


Subacute •• 


f 1870 
( 1871 


Chronic " 


f 1870 

1 1 OT1 



M. 


F. 


35 


2 


42 


2 


216 


51 


159 


47 


12G 


11 


90 


14 



This fact has been confirmed by statistics collected by the Health De- 
partment of New York. During the year 1873, 45 deaths were reported 
from delirium tremens, but four of whom were females. It is probable that 
there were many more cases which were not reported as such. 

Women, however, though not so subject to chronic alcoholism as men, 
often drink to excess, and not rarely develop delirium tremens. This 
bad habit is confined chiefly to either extreme of society — the very lowest 
class, or the highest in the social scale. Among the latter the amount of 
private dram-drinking is astonishing ; and though the "skeleton in the 
closet" is carefully guarded by the friends of the patient, it is by no means 
uncommon for the physician to be called in to attend cases of delirium 
tremens in high life. 

Absinthe, which is extensively used in Paris, and is beginning to be 
introduced into this country, produces a terrible form of delirium tremens, 
in which mania is a marked feature; and a form of epileptiform attack is 
also quite common. 

Alcoholism is much more often observed between the twentieth and the 
fiftieth year, and is very rare before that time. 

As to hereditary predisposition there is a great deal to be said, but when 
we attempt its consideration we depaYt from the immediate subject. Oc- 
cupation and mental influences have much to do with the making of drunk- 
ards or hard drinkers. Barkeepers, and individuals exposed to severe 
weather, are commonly addicted to drink ; the one either feeling obliged 
to be convivial or indulging only because the liquor is SO accessible, and the 

other because he " needs something to keep out the cold." Mental depres- 
sion, grief, and business worry are interesting in their social features, but 
do not Strictly conic within the scope of an article of this character. 

Morbid Anatomy and Pathology The prolonged use of 

alcohol is followed by marked changes in the structure of the nersous 
Substance. In the early Stages there may be found appearances which 

are ordinarily met with in uncomplicated cerebral congestion, viz., enlarged 

\ essels, injected meninges, and elVusions of serum. These may \ ary greatly 
in their extent and appearance, and may he associated with a fatty degene- 
ration of the vascular walls, patches of softening, or even Little foci of in- 
duration. The disease l<*\es its traces most indelibly stamped as menin- 
geal thickening and opalescence, and perhaps encysted collections of blood, 
which have been described in Bpeakingof pachymeningitis. The sinuses 
are engorged, and the dura mater may be adherent to its underlying mem- 



ALCOHOLISM. 357 

branes ; or they, in turn, may be in such close contact in spots with the 
cortex that their removal necessitates the tearing out of patches of super- 
ficial gray Bubstance. The convolutions will he found t<» be atrophied and 
reduced in Bize, and the ganglia at the base are often greatly softened. 

Many observers, among them Carlisle and Percy, have found alcohol in 
the fluids in the ventricles. Besides these intracranial changes, the liver, 
kidneys, and stomach present appearances with which all pathologists are 
familiar. The arteries throughout the body are found to have undergone 
atheromatous degeneration, and this is Been in the brain ton very decided 
degree. As to the condition alluded to by various observers, viz., the 
mechanical change exerted directly by the contact of alcohol with the tis- 
Bues, I think there has b»-en much exaggeration. The sclerosis so often 
Been is much more probably the result of interstitial inflammatory change 
than a chemical transformation. 

The experiments made by Anstie, 1 Magnan, 9 Percy, Marce5t, a and 
Motet 4 settle with great certainty the pathological processes which follow 
the toxic administration of alcohol. Anstie took a full-grown dog weigh- 
ing 10 lb. 4 ozs.. and injected 6 ozs. of mixed alcohol and water into the 
stomach at 1 P. M. Xo food had been taken for four hours previously. 

1.4P.M. Animal obviously affected: staggers in walking, and fre- 
quently falls down. The hind quarters are weak, and skin of hind limbs 
insensitive. Resp. 24; circulation, 140. 

l.G P.M. Dog lies extended on the floor quite drowsy, but capable of 
being roused : fore-limbs retain slight degree of voluntary power. Tongue 
protruded, and the dog ••slavers" still. Skin about mouth anaesthetic; 
conjunctiva sensitive. 

1.7.30 P. M. Animal falls on its side, comatose and snoring. Conjunc- 
tiva insensitive with other parts. Resp. 20; circulation. 184, tolerably 
strong. Ano-genital region was sensitive to painful impressions. Pupil 
strongly contracted at first, but became dilated at 1.25, little sensitive to 
light: anaesthesia remained ; eyes still insensitive; continuous tremor of 
hind-legs began and continued for a short time. Respiration declined in 
frequency and became gasping, and ceased at 3.5 P. M.. two hours after 
the ingestion of the alcohol, the heart beating li-1 per minute. It remained 
irritable for some minutes later. Much more complete and earlier coma 
followed the administration of larger d< 

The continued toxic use of alcohol produces changes not only upon the 
nervous system directly, but secondarily through other organs which are 
primarily affected. .V large quantity of alcohol taken into the BVStem in- 
duces pathological changes somewhat after the following manner: A cer- 
tain portion, quite small in amount. is excreted, and may be detected in 
the breath, urine, bile, ami sweat, while the greater proportion remain- in 



1 Stimulants and Narcotics, p. 335 et seq. ■ Op. cit., p. 117. 

•' De la folic causee par I'abus des boissons alcooliques, these de 1847. 
4 ( onsiderations generates but L'alcoolisme, et plus particulieremenf d< - 
taxiques sur I'homme par la liqueur d' absinthe, L8 



358 



CEREBROSPINAL DISEASES. 



thf blood, greatly altering its character and inducing a large number of 
interesting changes. Lallemand, Marce*t, and various experimenters have 
found that the excretions contained much pure alcohol, and others have 
detected, by the chromic acid test, traces of alcohol forty-eight hours after- 
wards. Anstie declares, however, that but the merest fraction of the 
amount taken is eliminated in its unchanged form. In this conclusion he 
differs from the authorities I have quoted. The alcohol remaining in the 
blood is partially eliminated in its decomposed state (carbonic oxide and 
water), while a certain quantity remains. The internal organs are con- 
d, notably the liver, kidneys, and lungs, so that excretion is very 
slowly performed, and the urine voided is scanty in amount, devoid of 
the chlorides, and rich in urates. The blood circulates sluggishly, and 
contains fat and sugar. I have also found sugar in the urine, which pro- 
bably resulted from irritation of the medulla as well as certain disturbances 
of kidney and liver function. 

The abundance of carbonic acid requires double duty upon the part of 
the lungs, and consequently respiration becomes labored and quickened. 
The natural oxidation of the blood is seriously embarrassed, and elimina- 
tion is retarded most seriously. 

The nervous system of course suffers from this change in its badly nour- 
ished state. Degeneration of the nervous elements follows, and interstitial 
thickening and medullary metamorphoses take place, so that the loss of 
function is very great. The pneumogastric being implicated, the lungs 
and other organs are not properly innervated, and many of the curious 
evidences of such disorder follow. This is illustrated by the tendency to 
pneumonia which often exists as a feature of alcoholism. 

The sympathetic system is of course implicated. The actual presence 
of alcohol is attended by vaso-niofor paresis, and a. number of vascular 
changes probably follow. It might be well, before closing, to refer to a 
condition of the cranial bones noted by Laneoreaux and others. A hard- 
ening ami thickening is due to nutritive changes, which Anstie thinks is 
not a true hypertrophy, as the original texture of the bone is lost. 

Prognosis A table prepared by Mr. Neilson from the Registrar- 
General's report shows that the probable duration of life in individuals 
who have reached the 20th, 30th, loth, 50th, and 60th years, and who 
have been either temperate or intemperate, is about the following: — 



Having reached 


Bas mi averagechance 


But the Intemperate have an average chance 


t \m- age "t 


nt ,-tiii surviving 


of sun Iving onlj 


•jo 


1 1.21 years 


i 5.58 ) ears, or 85 per ct . of the duration of 
life of the general population. 


80 


86.48 " . 


18.80 •' ■• 88 


in 


2S.7!) '• 


1 1.62 " 4t 40 " '• " 




21.25 <* 


lo. si; " •• ,,i 


Co 


i 1.28 " 


8.94 " " 68 " " 



This applies only in ;i general waj i<> the subject, but is significant in 
showing ho^ groatlj the alcoholic habit diminishes the patient's chances. 






ALCOHOLISM. 359 

In regard to the prognosis of the actual attack, there is rarely any rea- 
son to fear a fatal termination unless the patient has had a number of 

previous ones. Coma and convulsions should be looked upon with grave 
suspicion, as they greatly diminish the patient's tendency to recovery. 
Chronic alcoholism is more unfavorable Should the patient survive 
his immediate nervous trouble, it is very likely thai disease of some 

other organ will carry him off. Much depends upon his ability to reform ; 
and no assurance can be given that he will recover until this i- accom- 
plished. 

Diagnosis The only diseases for which alcoholism may be mistaken 

are: 1. General paralysis; 2. Sclerosis, and paralysis agitans ; 3. Soften- 
ing; 4. Dementia. 

1. General paralysis differs from delirium tremens in the fact that in the 
former the delusions are always pleasurable and exalted. The general 
paralytic is tin 1 king, the capitalist, the ruler of the universe; tin- alco- 
holic patient is depressed, dejected, and sad. These differences, taken into 
consideration with the fact that the patient suffers from anorexia, that his 
face is flushed, and the conjunctivae red, ought to settle the real nature of 
the trouble. Anstie 1 alludes to the presence of acne as a pathognomonic 
sign. Chronic alcoholism may very closely resemble general paralysis, 
but there is more proper dementia in the latter. 

2. Sclerosis and paralysis agitans are sometimes confounded with chro- 
nic alcoholism when there is much disturbance of coordination. The 
tremor and incoordination are much greater during voluntary action, how- 
ever, in the first conditions, and there is rarely any mental disturbance in 
either. 

3. Softening resembles chronic alcoholism, but the paralysis and speech 
disturbance are much more pronounced, there generally being aphasia, and 
the headache besides is quite different from that of alcoholism. 

4. Senile dementia may make the diagnosis somewhat difficult. The 
previous history of the patient, however, will generally clear away any 
doubts that may arise. 

Treatment — The physician's first attempt should be to prevent the 
patient from further indulging his depraved appetite. How this is to be 
accomplished depends very much upon his surroundings, temperament, 
and condition. If the attack arises during a debauch, I prefer to cut 
off at once the supply of alcohol, unless he is utterly prostrated. If 
the attack occurs after cessation, we may then give small quantity 
stimulants, and •• taper off." Should he be irritable and excited, immediate 
recourse t<> sedatives mid hypnotics should be had (FF. 87, - ; . I. 33, 
'■J' 1 . 23). I have great faith in the bromides, lupulin, or simple reme- 
dies of this class. Fifteen or twenty grains of the bromide of calcium, 
given in a drachm of the tr. lupulin twice or three times a day, is often 
sufficient to quiet the nervous Btate. A good cathartic which shall increase 

the action of the liver, and hasten elimination of the alcohol, is an early 
1 Article on Alcoholism, Reynolds's System, vol. ii. p. 160. 



360 CEREBROSPINAL DISEASES. 

form of treatment which is generally recommended. Should the insomnia 

be troublesome or the delirium violent, we may administer either the 
bromides, or the mono-bromide of camphor (F. 87). which I make the 
claim of being the first to use for this purpose. It mar be given in pilu- 
lar form, made up with confection of roses, in doses of five grains every 
hour until sleep is produced. The bromides of calcium or sodium in thirty 
grain doses every two hours sometimes succeed, or, better still, they may be 
combined with chloral hydrate, so that the patient shall take fifteen grains 
of each every two hours until the excitement subsides. Cannabis indica 
( IT\ 81, 39) has enjoyed great popularity in the treatment of this trouble, 
and should be given in doses of from one-half to one grain of the extract. 
Should the maniacal excitement be intense, I know of no better remedy 
than morphine administered hypodermically, but not by the mouth, as it 
may lie unabsorbed for some time without producing any effect; and the 
physician may be tempted to give still more than the ordinary dose, when 
to his surprise absorption takes place, and its cumulative action follows. 
Digitalis has been recommended in large doses, and Anstie preferred the 
powder because the alcohol of the tincture interfered with the proper action 
of the drug. I am inclined to think that the application of digitalis stupes 
to the lumbar region and the abdomen favors kidney action, and does more 
good than when the medicine is given by the mouth. 

It is of importance that the action of the skin and bowels should be 
increased. For the first object, small doses of tartar emetic assist the 
emunetory action of the skin, while the compound jalap powder induces 
copious and watery discharges from the bowels. Cold to the head, either 
by ice-bags or cloths wet with ice-water, blisters to the calves, and local 
abstraction of blood may be resorted to in violent cases. As to food: 
when the worn-out stomach refuses all ordinary articles of diet, it will 
rarely reject iced milk, which may be* given in all cases. After a while 
soups, nutritious broths, or bouillon made from beef, or Valentine's beef 
juice, or Borden's extract of beef, either of which is preferable to the Liebig 
extract on account of the nauseous taste of the latter, may be given in lib- 
eral quantities. Small doses of carbonic acid, seltzer, or Apollinaris 
water, or coffee may be administered before eating, and gently stimulate 
the Btomach, in this respect taking the place of the drams. 

Tic patient'- naii-ea may be corrected by the aromatic spirits of ammo- 
nia, or bismuth and morphine (FF. 89, 34, •">•">). the latter in very small 

In chronic alcoholism the aim of the physician should be to restore the 

normal action of the i iscera ; to stop the supply of drink; and to freely admin- 
ister the various preparations of iron, quinine, and phosphoric acid, as 
well as cod-liver oil (FF. 8, 9, 10,82, 1<». 12). I have found thai the 
new preparation known a- diarj&ed iron (F. 1 1 ) is well borne h\ the irri- 
table stomach, does not constipate, ami is therefore an excellent remedy. 
This may !>'• given with tr. digitalis and tr. mix vomica (F. '.'<>). 






IIYDROPIIOBIA. 301 



HYDROPHOBIA. 

Synonyms. — Rabies canina; Paraphobia; Lyssaphobia (?). 

The name adopted to express that form of nervous trouble wbicb some- 
times follows the bite of a rabid animal is an evident misnomer, as the 
definition of the term signifies "a dread of water." A< this is bu1 one 
symptom, and by no means a constant one, the firsl synonym is much 
more expressive and appropriate, and is in every way preferable to that in 
general use. 

Symptoms 1. Period of Incubation After the receipt of the 

bite, which may produce an extensive wound, or, a< is the case Bometimes, 
an insignificant scratch, a period of time extending from a few month- to 
several years may elapse before the appearance of the Becond stage. The 
wound may heal by first intention, giving rise to no inconvenience, or 
there may be redness and neuralgic pain. A history of this kind is 
usually given by the patient, and is based upon an exaggerated statement 
of the actual facts, which arises from a disordered imagination, while his 
story of the accident and of his subsequent symptoms is tinctured with a 
decided flavor of romance. Nervous derangement dependent upon fear. 
digestive disorders, mental worry, and others of the same category, gen- 
erally characterize this first stage. 

2. Period of Invasion At the end of the period of incubation, the 

first alarming symptoms noticed are those connected with the cicatrix, 
which becomes painful and tender, and at the same time there are pains 
which dart along the nerves in the vicinity. There are next generally head- 
ache and a sense of epigastric oppression, with constipation, broken Bleep, 
and a feeling of general discomfort. At the end of two or three days, 
during which the patient suffers intensely, we may expect the appearance 
of the next stage. 

3. The Period of Development With aggravation of the symptoms 

just enumerated, we find added thereto a sense of constriction about the 
throat, irregular and quickened respiration, rigidity of the muscles of the 
neck, discomfort in deglutition, and spasms, which begin in the muscles of 
the throat and back of the neck, and gradually invade those of the hark. 
The spasms give rise to much pain, which is sometimes spinal and at others 
muscular. The patient is at this stage delirious and flighty, and gene- 
rally has delusions in which dogs play an important part. The difficulty 
of swallowing, which next follows, is not so great when solids are taken. 
Fluids, on the contrary, seem to produce an aggravation of the Bpasms, 
and the mere sound of splashing or trickling water will excite a convulsive 
seizure. To add to the sufferings of the patient, there is excessive thirst, 
which is very distressing. His face becomes dusky, and his eyes promi- 
nent and wild. lie tosses from side to side it' placed in bed. the saliva 
running from the angle of the mouth in a viscid -tivjiin. Toward- the 
end of the disease tlii- secretion becomes thicker and mixed with D1UCUS, 
and it collects in the trachea and bronchi. These symptoms may last 



362 CEREBRO-SPINAL DISEASES. 

two or three days, while in the moan time the reflex excitability becomes 
eat as to precipitate a convulsion under the least stimulus. The 
pulse is rapid, the headache more severe, the air-passages become filled, 
and respiration is greatly interfered with. The convulsions are readily 
produced by blowing upon the patient, or by jarring him, or even by slam- 
ming the door. At this stage he becomes partially unconscious, is quite 
delirious, and very much agitated. Previous to death there is a marked 
rise in the temperature, and in one case I saw, the history of which I shall 
presently relate, the temperature rose to 103°, and I believe there was 
even a subsequent rise. Hammond considers that it may often reach 110°. 

Death occurs in two or three days in most cases, but it may lie delayed 
a day or two longer. Incontinence of urine and feces precedes the end ; 
tin 1 immediate cause of death being asphyxia from spasmodic stenosis of 
the larynx, or obstruction of the air-passages by mucus. I had the 
privilege of seeing one case at the request of Dr. Augustus Yiele, of the 
Health Department of the city, which was subsequently reported by Dr. 
Iladden. 1 

Through the courtesy of Dr. Iladden and Deputy Coroner Leo, I was 
also enabled to observe the post-mortem appearances of the brain and cord 
after the patient's death. Dr. Iladden describes the case so clearly, that 
1 shall mainly use his own words. 

" On the 24th ultimo, at 8.30 P. M., I was called to attend a young 
man named YVm. McCormick, residing at No. 309 East 51st Street, a 
native of this city, aged 26 years, athletic in appearance, of usually good 
health, nervous temperament, and of moderately temperate habits; by 
occupation a drive* of an express-wagon, lie was in bed, complaining 
of nervousness, soreness in his neck and throat, strange feelings of tight- 
ness around his chest. His countenance was anxious, pupils of his eves 
were dilated, and his general appearance was like one who was in fear of 
impending danger, and not in extreme pain. He told me that his throat 
was so sore that he could not swallow anything — not even water. This, 
he thought, was due to some simple medicine he had taken, and not to 
any serious ailment. I noticed his throat was not swollen on the outside, 
and thai his voice was whining, and unlike a person suffering from any 
ordinary soreness within. I, however, examined his throat within, but 
found nothing to account for this difficulty ; it was perfectly healthy in 
appearance. His pulse, respiration, and temperature were normal, ex- 
cepting an occasional sigh. I observed, also, a little disposition to hack 

and spit, but in no way troublesome. lb' complained also of thirst, but 
said he could not drink, he knew, for the very sight of water made him shud- 
der. I told him his throat was not sore, and urged him to try. He assented, 
and water was accordingly brought, which, at sight, caused a violent spasm. 

He threw himself an 1 in the bed, forward and backward, and told the 

party to take il away at once, as it would kill him. He immediately 
afterwards culled for the goblet* and said he was very thirsty and must 
drink, seized it, and with a jpoifenl effort succeeded in taking a single 

1 .Journal of Psychological Medicine, May, 1870, p. 80. 






HYDROPHOBIA. 303 

swallow, which was followed by a severe convulsive shudder and contrac- 
tion of the muscles of the neck and chest." Dr. Sadden ascertained the 
fact that he had been bitten by a dog, and then inquired about the symptoms 
antecedent to Ids visit. " Wednesday and the two preceding days he was 
complaining of general lassitude and nervousness ; had not been able to 
sleep at night ; was thirsty, arid had drunk a great deal of water; had 
eaten but little; appetite very poor, and on Wednesday afternoon he 
seemed to be growing worse. He went out upon the street, but soon re- 
turned, saying that it was very chilly, and he could not Btand the air at all. 
While taking a, cup of tea at 6 P. M. the same evening, he first showed 
signs of difficulty in swallowing. Shortly afterwards, as he was going to 
the kitchen, he was met by a draught of cold air, which so staggered him 
that he nearly fell ; he then went to bed, where J found him. After 
giving the necessary caution to the family, I ordered fifteen grains of 
bromide of potassium to be given every hour. I left, and returned at 
10.30 P. M. . . . Found him in about the same condition I had left him, 
only his pulse was irregular, and his spasms more frequent. The saliva 
was a little more troublesome, and he also could not swallow without 
great difficulty. I was called again at 2.30 A. M., the messenger stating 
that the patient had become very violent, and that they were unable to 
restrain him. I went immediately. . . . Found him in a frightful - 
of excitement ; had broken down the bed, and was straggling with his 
attendants to get at liberty, lie was shouting and crying out to them to 
let him go, and called for water, which, when brought, he could not drink. 
His mind was clear, and he knew all those around him; was spitting a 
viscid saliva-, but was careful not to spit upon any one, not even on his 
clothes. It was so abundant that his attendants were obliged to wipe it 
from his lips. Dr. Leavitt and myself, after viewing the case in all its 
aspects, concluded to inject in the tissues of the leg half a grain of mor- 
phine and one-sixty-fourth of a grain of atropine in solution, which was 
done at 3 A. 31. by Dr. Leavitt. We carefully watched the effect till 3. -■'>'» 
A.M., when, his violence having in no way abated, another injection was 
given in the same part of three-eighths of a grain of morphine and one- 
eighth of a grain of atropine, which in some degree produced the charac- 
teristic effect of morphine, and very clearly the appearances of the atropine ; 
for, notwithstanding he was struggling violently, the saliva, which had 
been very troublesome, was completely dried up; so much so that the 
patient remarked that he was very thirsty, and his -mouth felt as if he had 
been chewing a. brick.' Fifteen drops of chloroform were then injected, with 
no effect whatever, unless to weaken his already weak .and frequent pulse. 
A i 4.15 A.M. three-eighths of a grain of morphine were again introduced 
under the skin without atropine. This quieted the patient, so that he was 
easily restrained, and he remained in this condition from 4.30 till 1<» A. M.. 
when the effects had so far passed off that the attendants were alarmed 
at his violence and the abundance of saliva that he was spitting from his 
mouth. At 10.15 A. M. three-eighths of a grain of morphine in solution 
were injected in the tissue of the thigh, which served to temper down the 

increasing violence of the spasms, but did not stop the flow of salixa. I 
accordingly, a1 10.45 A. M.. injected three-eighths of a grain of morphine 
and one-fortieth of a grain of atropine, which had the desired effect of 
producing the quieting effeel of the morphine and the specific effect of the 
atropia on tin' salivary glands. The poisonous effects of the morphine and 



361 CEREBROSPINAL DISEASES. 

atropia wore at no time apparent. He died at 4.15 P. M. June 2G, 1874, 
about twenty-four hours after the first spasm." 

Dr. Hammond saw the patient on the morning of the 2Gth, and corrobora- 
ted Dr. lladden's diagnosis. I saw him at three o'clock of the same day, and 
found him lying upon the floor bound with twisted sheets, the ends of which 
were held by his attendants. He was very violent, and, though there were 
no very marked convulsions, he seemed to be quite rigid, and his forearms 
were flexed during most of the time. He was semi-comatose, and groaned 
occasionally, but took no notice of those about him, and did not speak. 
His respirations were quick, and there was a rattling sound produced in 
his throat with each expiration and inspiration. A quantity of quite thick 
mucus and saliva was spat up during my visit, and there seemed to be a 
very free secretion of this substance. The pupils were widely dilated, and 
as tar as I could judge there was no marked elevation of temperature. 1 

Recent cases of hydrophobia have been reported by Francois, 2 Edwards, 3 
Smith, 4 and Ilanscom. 5 The case of the latter is so interesting and so 
graphically detailed, that I shall take the liberty of giving it in its entirety. 

On the morning of the 20th of November a good-natured pet spaniel, 
which had never been known to sua]) at any one, suddenly and without 
any provocation sprang at his mistress. His master whipped him, and 
he was left in the cellar of the house until the time for his dinner. 
While eating it in the company of a pet cat, as he had been accus- 
tomed to, without ever having molested her, he suddenly seized the cat 
and threw her across the room. The owner reached out his hand to catch 
the dog, when the latter caught him tightly by the wrist and inflicted a 
deep wound, biting him three times; the skin became lacerated while 
making an effort to shake him off. It was supposed at the time that the 
dog was irritable from the whipping which he had received in the morning, 
and. ;i- he expected another for snapping at the eat, defended himself by 
biting. Half an hour after, the patient applied to me for treatment, and 
believing it to be too late for excision or cauterization to be effective, and 
a- there was no history of hydrophobia, I dressed the wound with a solu- 
tion of carbolic acid. It healed readily, and the patient attended to his 
business as usual in four or five days. Soon after the infliction of the bite 
the dog disappeared and he did not return for thirty-six hours; nothing 
ecdihl be ascertained of his whereabouts or of his behavior during that time. 
When he returned lie was very much exhausted, and had the appearance 
of having been Beverely beaten. From what I can learn of those who saw 
him he gradually grew weaker, apparently Losing the use of his legs, espe- 
cially the hind ones, which he would drag after him. lb' died quietly, 
with his head in the lap of his mistress, without having had a convulsion, 
excessive flow of saliva, or tremors. On the L3th day of January (fifty- 

1 In tlii^ case Hi.- newspapers were filled with sensational accounts of the patient's 
illness, and an attempt was made to prove thai tli«' dog was not mad. It is need- 
thai such wras juoii.ilik ool the case, and it is to lie regretted that the 
i • nei er found. 
Bo t. Med. and Surg. Journal, May 17. 1877. :l [bid., March 15, L877. 
i Ibid., March 15, 1877. ' Ibid., April 19, 1877. 



HYDROPHOBIA. 3G5 

four days after the injury), the patient began to have shooting pains in 
the forearm, but not especially localized. They did not radiate from the 
cicatrix, and there was no change in the appearance of the latter. On the 
following day the pain had increased so much that lie required one-sixth 
of a grain of morphia to relieve him; it was given Bubcutaneously, and 
was repeated the next morning. After that there was very little pain in 
the arm, and no appreciable change in the pulse or temperature, lb- was 
despondent, and stated on the morning of the 15th that ' he felt sick and 
used up all over;' he was obliged to go to bed in the afternoon, and then 
for the first time began to have some difficulty in swallowing. This symp- 
tom was not manifested by an attempt to drink water, but during an effort 
to swallow some herb tea which he was accustomed to take when ill, and 
which he believed would relieve his bad feelings. There was do trismus; 
he was quiet and inclined to doze. At 5 P. M. Dr. II. II. A. Beach saw 
the patient with me, and agreed that the history of the case in connection 
with the symptoms then existing indicated the probable development of 
hydrophobia, and an unfavorable prognosis was given to the patient's 
brother, who promised not to communicate it to the patient or his friends 
until the disease should be fully declared. His pulse at that time was 102, 
and the temperature in the axilla 102° F., face flushed, tongue coated. 
The cicatrix presented no unusual appearance, nor was it tender. A dark 
room was agreeable to him, but on raising the curtains the light did not 
disturb him in the least. He was perfectly rational, and had some thirst, 
but no sore throat. He made an attempt to swallow a teaspoonful of milk, 
but was obliged to give it up from the moment that the fluid touched his 
lips. Immediately after this attempt unmistakable spasmodic contraction 
of muscles between the chin and sternum was observed. Mentally the 
patient was perfectly clear, and not disturbed by the unsuccessful attempt 
at swallowing fluids, but said he would try it again when he should be 
more thirsty. This symptom, excepting when he swallowed teaspoonful 
doses of medicine, continued until his death. He was obliged to relieve 
his thirst by sucking ice and snow through a napkin. The air from a tan 
or from adjusting the bed-clothing caused a shudder. Occasional sighing 
was noticed after the second day; it grew deeper and more frequent until 
the end. AVhen disturbed from any cause his respiration was of a spas- 
modic character, so much so at times as to interfere with his speech. 

On the following morning (the lGth) his pulse was 96, and mild de- 
lirium first developed ; this also continued until his death. lie was easily 
controlled throughout the disease. He became very suspicious of the 
people about him, believing that they were attempting to make him the 
victim of practical jokes, then of being poisoned. One hallucination was 
continuous from the time that the delirium first developed : he thought 
that some one had thrown a dirty powder on him. and he was continually 
making efforts to shake it off from himself and his clothing. lie was also 
Very cross and dictatorial, but showed no disposition to snap or bite. 

Between four and five P. M. on the L8th he began to have spasmodic 

contraction of the muscles of the chest, larynx, and throat : some of them 
lasted nearly a minute, and prevented him from taking an inspiration. 
lie also had a profuse discharge of saliva sufficient to wet his clothing 
through from his chin down to his hips. The spasmodic contractions con- 
cerned in respiration exhausted him rapidly, and he died quietly at 8.15, 

while sitting up in a chair. This position became necessary from the fact 

that he could not lie on his side, and if on his back the saliva accumulated 



366 CEREBRO-SPINAL DISEASES. 

BO rapidly that it obstructed his respiration. For the last twenty minutes 
before his death there was no spasm. He lived five days after the first 
general symptom. At no time was he disturbed by the sound of ringing- 
bells or running water. Morphia in one-tburth-grain doses, and chloral and 
bromide 1 of potassium in fifteen-grain doses of each at the same time were 
given as needed. Anaesthetics were not required. At the solicitation of 
his friends he was allowed to take a pill, the prescription for which was 
said to bo one hundred years old and to have cost originally five hundred 
pounds. It had the reputation of curing and preventing many cases of the 
disease. No change in his symptoms could be attributed to its action, nor 
could its composition be ascertained. It was given as a placebo, on the 
chances that an hysterical element existed in this case ; that whatever 
offered encouragement to the patient without the possibility of injury in 
hi- hopeless condition was justifiable, but so far as the evidence furnished 
by one case is of value its inefficacy was demonstrated. The permission 
of the friends for an autopsy could not be obtained. The particular symp- 
toms of the disease which were not observed in the dog when seen might 
have existed during the thirty-six hours that he was absent. 

The proximity of the wound to the ulnar nerve and its character 
(punctured and lacerated) suggested the consideration of tetanus as an 
explanation of the symptoms; the latter seemed to be fairly excluded, 
however, on the ground that delirium was continuous from the third day 
of the attack, and that at no time did trismus or any other form of tonic 
Spasm exist; the profuse discharge of saliva was also corroborative of this 
view. The unquestionable existence of repeated attacks of laryngeal 
spasm ; the fact that the symptoms developed after a considerable interval 
had elapsed from the date of the injury; that for three hours previous to 
his death, and after he became wholly unconscious, marked spasms of the 
chesl and throat occurred at intervals of from three to live minutes; that 
death occurred as a result and within five days following the development 
of symptoms characteristic of the disease, reasonably offsets a theory that 
the hydrophobic symptoms were simulated by an hysterical man. 

In Smith's case the period of incubation waB about two months, and the 
paroxysms were ushered in by vomiting, fear of water, and febrile symp- 
toms. On the third day of the disease he became delirious, and on the 

fourth died. The sound made by the patient, which is so often compared 
to the bark of a dog, was likened by the author to that made by a croupy 
child. In Edwards's case, the period of incubation was about five months. 
The injury was insignificant, but with the invasion of the disease there 

was pain in the cicatrix which extended up the arm. In this patient there 

wa8 also dread of fluids, especially water. On the second day the COnvul- 
Bions began. The sane- da\ -he ,-pat up bloody mucus. At the end of 
.-i\t\ hours from the first local pain she died. 

Causes The circumstances which concern the etiology are still 

enshrouded in mystery. Hammond is of tie 1 opinion that rabies may be 

Communicated by a dog that is not mad, and brings forward Several cases to 

prove hi- theory. I cannot agree with him, for it seems to me highly im- 
probable thai there Bhould I"- bo lew cases of this disease if the bite of a 
non-rabid animal can inoculate an individual. Bouley states that in no 
waj can the di.-«\-i-<- be transmitted other than by inoculation with the saliva. 



HYDROPHOBIA. 36? 

In this statement lie receives the endorsement of Magendie and others. 
Another point remains to be answered, and this is in regard to the trans- 
mission of virus from one person to another without the second person 
being bitten. Fleming has given an example which show- that this may 

take place. 

In the spring of the present year I was subpoenaed to Berve as a juryman 
in the case of a boy who had died of rabies. At about the same time 

another death occurred which the attending physician said was -imply the 
result of fear, and not of hydrophobia. A careful inquiry and examination 
of witnesses revealed the following history, which I think proved beyond 
a doubt that the cause of death in both cases was the bite of a rabid cat. 
This cat had found her way into a stable on Thirty-fourth Street, and had 
bitten a horse. This horse afterwards died in convulsions, and from all I 
could learn the cause of death was hydrophobia. In an adjoining yard the 
cat bit one of the boys, who also died, and a few days afterwards hit the 
other boy, whose inquest we attended. Both of these victims died within 
a short time of each other. In one of these cases there was but a slight 
scratch. 

Morbid Anatomy and Pathology Clifford Albutt, 1 Meynert, 

Elder, 2 and Hammond 3 have all made autopsies, and still there seems to be 
very little light thrown upon the pathogeny of the disease. Hammond 
found granular degeneration of the nerve-cells of the cortical layer of the 
brain, and extravasations of blood in the medulla with destruction of cell- 
contents. The gray matter of the nuclei of the pneumogastric and hypo- 
glossal nerves had undergone granular degeneration. Albutt found en- 
largement of vessels in the cerebral convolutions, pons, medulla, and spinal 
cord, and granular disintegration. Elder found absolutely nothing ; and 
Lockhart Clarke, who examined parts of the brain, medulla, and cord. 
found the utter absence of any lesion. 

Kolesnikoff 4 reported the appearance of the nervous centre in ten dogs 
that had died of hydrophobia. ""The parts examined included the hemi- 
spheres, corpora striata, thalami optici, cornua ammonis, cerebellum, me- 
dulla oblongata, spinal cord, the sympathetic and vertebral ganglia. The 
most marked changes were observed in the two latter, and were as fol- 
lows : 1. The vessels were enlarged, choked with red blood-corpuscles: 
occasionally, extravasated red corpuscles and round indifferent elements 
(probably white corpuscles) were found in the perivascular -paces. The 
walls of the vessels were here and there tilled with hyaloid masses of vari- 
ous forms, which occasionally extended into the lumen of the vessels, and 
closed this as a thrombosis would. Not far from these masses collections 
of white and red blood-corpuscles could be observed, the latter deprived of 

color. They could be Been also in all stages of metamorphosis into bya- 

1 Med. Record, i. 22. 2 Dis. of Nervous s_\>U'in. pp, 

3 lb-it. Med. Journ., vol. ii. 1871. 

4 Centralblatt fur Med. Wissen., No. 50, 1875, Al»t. Phil, .Med. Times, 
Ed). 5, 1S7G. 



& 



368 CEREBRO-SPINAL DISEASES. 

loid globules. 2. In the pericellular spaces of the nerve -cells could be 
observed collections of round indifferent elements, whose penetration, to 
the number of live to eight or even more, pressed out the protoplasm of 
the cells. This penetration of the elements spoken of was frequently suffi- 
cient to change the form of the nerve-cells, giving them at different times 
a sac-formed, bulged, or flattened-out appearance. Further, the nucleus 
was sometimes pushed towards the periphery of the cell and surrounded 
by many round elements. In other cases, only groups of round (indif- 
ferent) bodies could be observed in place of the nerve-cells. In isolated 
nerve-cells the changes described could also be observed." 

The body of Dr. Hadden's patient was examined by the deputy coroner 
and several physicians, among whom were Drs. Clymer, Hammond, Cross, 
and myself. The calvarium was removed, and great congestion of the 
meninges and brain was observed. The sinuses were much engorged, but 
there was very little effusion either upon the surface of the brain or in the 
ventricles. The lower surface of the brain appeared to be slightly softened 
in patches, but there was nothing else to attract attention, except it might 
perhaps have been a great hardness of the pituitary body. Dr. Hammond's 
microscopical examination was subsequently made, and I have already 
alluded to its results. The internal viscera were all hyperaemic, but 
there were no other morbid appearances. The larynx and trachea were 
found to be very much injected, and the latter contained a quantity of 
frothy mucus. Dr. AVillis has found the blood of persons who have died 
from this disease to be very fluid and of a dark color. 

The question to be answered is, whether this affection is a primary dis- 
order of the nervous centres or whether it is the result of general blood- 
poisoning. I am inclined to accept the latter theory, as the array of facts 
is too meagre to permit any positive assertion as to its nervous origin. 
hike other disorders, not essentially nervous, there is a period of inocu- 
lation, of incubation, of invasion, and development. I think, then, that 
in this respect this disease, as well as tetanus, resembles closely some 
of the exanthemata. Hammond compares the disease with tetanus, epi- 
lepsy from reflex causes, and other neuroses of the same description, and 
is inclined to consider it a nervous disease per se. 

Diagnosis. — It is important to bear in mind the fact that a great 
many BO-caUed eases of hydrophobia are not this disease at all, and that 
certain tonus of hysteria bear to it a close resemblance. Fright may 

:n! 90 powerfully upon the aervOUS system that a train of symptoms may 

be produced very much like those of the genuine affection. A ease of this 
kind occurred at Bellevue Hospital a year orcwo ago, in which the symp- 
toms counterfeited those of the real disease in every respect, and the patient 

anally died. It was found that the individual had not only never been 

bitten, but that he actually died of fear, bis imagination having been 
stimulated by tin- sensationa] articles in the newspapers. Dr. J. W. S. 
Arnold, of the University, who examined the brain and cord, was unable 
to find the slightest Indication of any morbid change. The only othoi 






HYDROPHOBIA. 309 

conditions from which we may be required to make a differential diagnosis 
arc. tetanus, Calabar bean, and picrotoxin poisoning. In the former there 
arc many points of resemblance, and occasionally a dread of* Liquids and 
a difficulty in swallowing. In tetanus, however, the risus wrdonicug 
is present, the spasms are tonic, and there IS opisthotonos, and the mind 
is clear to the last. 

In poisoning by both agents, to which I have alluded, the rapidity of 
their action is conspicuous, and a dose of either would carry the patienl 
off in a few hours, more or less. In picrotoxin and Calabar bean poisoning 
there are many of the symptoms of hydrophobia, such ;i- clonic spasms, 
frothing, rise of temperature ; but no dread of water, nor delirium. 

Epilepsy may resemble hydrophobia, but it i> only when the attacks are 
numerous and closely connected that such a mistake could possibly occur. 

Marbaix 1 "gives a case of epileptiform convulsions more or less resem- 
bling hydrophobia, in a man who had been bitten four days before by a 
cat ; they were accompanied by delirium and hyperesthesia of the optic 
nerve, a stray Light thrown across his eyes causing a convulsive attack. 

The shortness of the incubation, the blueness of the face, without the 
k vultueuse' expression characteristic of hydrophobia, the delirium, and the 
melancholy, not exalted, condition, combined with a history of an epileptic 
attack a year before, prevented the case being looked upon as one of true 
hydrophobia." 

Prognosis In true hydrophobia it is very bad. I believe their 

never have been more than one or two genuine cures reported; and if others 
have been claimed, it is probable that no rabies existed, but that the affec- 
tion described was simply hysteria. The chance of inoculation seems to 
be a matter of interest, for of the reported cases in which individual- have 
been bitten, it has been found that about two-thirds of them subsequently 
developed symptoms of rabies. 

Treatment We rarely see these patients until actual evidences of 

madness have appeared. If, however, we are fortunate enough to be called 
to the individual immediately after he has been bitten, we may either incise 
or cauterize the wound. It is well to ligate the limb as soon as possible, 
and then remove en iikissc the piece of the muscle which has been pene- 
trated by the teeth of the rabid animal. Various writers recommend the 
cupping-glass, which should be applied to the excised part till it abstracts 
BeveraJ ounces of blood from the wound. .V pencil of nitrate of silver may 
be thrust into the punctures made by the teeth of the dog until they are 
well cauterized, and a strong solution (3U—oj) should be applied afterwards 
l»\ means of a piece of folded linen, which is to l>e covered 1»\ oil silk. 

I am convinced that no remedy can do good where the disease has 

already appeared, except, perhaps, curare, which ha- been tried; and in 
one case, where it was prescribed by Dr. Austin Flint, Si-., it is said to 

ha\ e saved the patient's life. 

The case must he desperate, howe\er, when this powerful SUbstanci is 



1 Presse Med. Beige, L869, 287. 
24 



3T0 CEREBROSPINAL DISEASES. 

resorted to. for its preparation is not always the same, and no two speei- 
ments are of the same strength. It lias been injected hypodermicaUy in 
doses of one grain. 

Offenberg 1 reports the cure of a girl of eighteen. She received at first 
hypodermic injections of morphine and chloroform, but there was no im- 
provement in her condition. Seven hypodermic injections, aggregating 
three grains of curare, were afterwards given in the course of six hours. The 
muscular disturbance subsided at once, and there was ultimate recovery. 
The convulsions were succeeded by paralysis, which gradually disappeared. 

II<»t baths have been recommended, but I cannot find that they have 
ever cured a case of this kind. 



HYSTERIA. 

Definition. — It would be almost impossible to give a concise defini- 
tion of this most protean of nervous affections, for it simulates a multitude 
of organic and functional diseases so perfectly, that the task of considering 
it in any systematic manner would be attended with great difficulty. The 
aervous system in this respect is like the "general utility" actor. It 
plays the most varied parts. Sometimes we are presented with a hemi- 
plegia or paraplegia, and at others with contractures which seem to be the 
result of organic disease, so permanent and intractable do they appear. 
Convulsions, anaesthesia, urinary and other troubles of a more or less 
grave character, swell the list, until we are almost inclined to look upon 
ii ;i- ;i "disease of the Devil," and cease to wonder at the credulity 
and BUperstitiOD of those who believe in demoniac possession and witch- 
Craft. Confining ourselves as closely to the subject as possible, we con- 
clude that hysteria, is a disease of an .emotional character chiefly among 
women, in which the symptoms are rarely the same in any two instances, 
but among a huge number of cases there can be noticed a certain simi- 
larity. 

Symptoms These symptoms may be grouped as sensorial, noto- 
rial, and visceral. Sensorial symptoms are of three hinds: hyperesthetic, 
anaesthetic, and mental. Hyperesthesia, though much more common than 

anaesthesia, IS not so marked. Large areas of hyperesthesia may be de- 
lected hv careful examination, though the patient usually saves this 

trouble, for Bhe calls attention to the weight of her clothes, the pressure of 
some told of her underwear, or the contact of some very light substance 
which i> pronounced unbearable. The extcFnal organs of generation are 
extremely sensitive, and the slightest touch <»t the finger or speculum pro- 
dine- ,-i spasm and great agony. 1 Coition 18 impossible, and one patient 



i Wien. Med. Presse, 1876^0. I. 
I have been able to >i<>i> at hysterical paroxysm bj firm pressure upon the 
ovary. Light pressure greatrj aggravated the patient's discomfort. Other ob- 
servers have called attention '" this phenomei , among them Charcot. 



HYSTERIA. 371 

called my attention to a horrible shooting pain which occurred whenever 
her husband approached her. Hyperesthesia about the nipples, at the 
end of the coccyx, and in other parts of the body, i.s alluded to by vari- 
ous writers. Charcot has directed attention to the prominence of these ; 
and Briquet lias described fixed pains of the abdomen which he called 
ccelalgice, and of 450 cases he found 200 presenting this symptom. They 
were hypogastric and iliac, but more commonly the latter. These have 
sometimes been mistaken for the pain of peritonitis; there is, however, 
no tenderness, but simply superficial elevation of sensibility. The patient 
often calls attention to vague pains in different pints of the body, of a 
transitory, and sometimes permanent character. She complains of strong 
light and loud noises, and insists upon perfect quiet, although she will her- 
self talk and cry in a very noisy manner. All of her pains are increased 
when her attention is concentrated upon them, but when her mind is 
diverted she will bear very rough treatment without complaint. 

Neuralgic pain, a familiar variety being the clavus hystericus, is a com- 
mon form of complaint. Various local pains are also experienced, and 
these, among others, include alterations in sensibility which simulate lum- 
bago ; indeed, a very constant hysterical complaint is backache, which the 
patient generally attributes to the kidneys. A most interesting form of 
hysterical dysesthesia has received mention from Skey, Paget, and others, 
and is very often mistaken for rheumatism. The joints are neither swollen 
nor red, however. Moriz Meyer, 1 in an interesting article upon the sub- 
ject, gives the leading points in diagnosis as follows : " 1. The neuralgia is 
of a diurnal form entirely. 2. Light pressure of joints produces pain, but 
comparatively violent handling is not at all painful. 3. The temperature 
Of the affected joint undergoes variations. 4. There is no loss of sub- 
stance of the muscles of an unsound limb. 5. The cure is usually spon- 
taneous." The mental disturbances are of the most interesting character, 
whether expressed by transient emotional excitement or apparent pro- 
longed unconsciousness. Examples of the lighter grades are too familiar 
to need description, and it is only necessary to allude to the outbursts of 
immoderate laughter or crying which occur when there is no reason for 
either emotional elation or depression. Such individuals may indulge in 
laughter at church or at a funeral, and, while perfectly aware of the im- 
propriety of their conduct, will be utterly unable to restrain themselves. 
Illusions, hallucinations, and even delusions are evidences of a very irri- 
table condition of the nervous centres, as are ecstasy and mental excite- 
ment of various kinds, such as belief in impending calamity or death. 
The involuntary use of foul words and gestures, and a remarkable eccen- 
tricity of behavior, are additional suggestions of a disordered Btate of the 

emotions. Wynter, s in his excellent little book, thus alludes to a condi- 
tion which, after all, is but a. manifestation of hy8teria. 

1 Berliner Klin. Woch., 187 i. No. 26. 

2 Borderland of [nsanitj . p. :>. 



372 CEREBRO-SPINAL DISEASES. 

"There is a terrible Stage of consciousness in which, unknown to any 
other human being, an individual keeps np as it were a terrible hand-to- 
hand conflict with himself when he is prompted by an inward voice to use 
disgusting words, which, in his sane moments, he loathes and abhors. 
These voices will sometimes suggest ideas which are diametrically opposed 
to the sober dictates of his conscience. In such conditions of mind, prayers 
are turned into curses, and the chastest into the most libidinous thoughts." 1 
The will is quite weak, while the emotions, far from being held in 
abeyance to the extent which the}' are in health, respond to trivial idea- 
tional impressions. The hysterical person firmly believes herself to be the 
subject of various disorders of a greater or less serious character; is hope- 
less; believes in a speedy fatal termination of her imaginary trouble ; and 
can only be convinced of her mistake by fear of the remedy suggested, or 
by some strong appeal to her appetite or comfort. While in a state which 
may sometimes appal the observer, the patient declares her inability to 
walk. If, however, some powerful excitement be produced, such as an 
alarm of fire, she quickly recovers the use of her legs. I have recently 
-ecu a most interesting case of hysterical torticollis, in which the patient, 
refused to turn or raise her head. I quietly seated myself at her other 
side, and engaged her attention so fully that alter a while she turned her 
head and talked for some time; and it was only when I referred to the 
subject of her troubles that she quickly resumed her original position, and 

I could not persuade her to change it. She may at times believe that she 
is deaf or dumb, and remain in such an uncomfortable condition for years, 
punishing not only herself, but making all about her uncomfortable. 

Hysterical anaesthesia has received a great deal of attention of late 
years from the French observers, especially from Charcot and Briquet, as 
well as Piorryand Gendrin. Briquet 2 has found that this condition occurs 
more frequently on the left than upon ♦Che right side. It may be superfi- 
cial or deep, even affecting the muscles and bones. Reynolds has found 
it limited often to the back of the hand or foot, or about the mouth and 
uose. The vaginal canal and the lining mucous membrane of the mouth 
are also places where there maybe loss of sensation. Hysterical anaes- 
thesia not rarely follows, or comes on during a convulsive attack, and 
lasts lor a variable time. It may subside in a. few hours, or continue for 

months at a time During its existence the most violent stimuli will 
fail to restore Bensibility ; and I have often u^nl powerful counter-irri- 
tant.-, electricity, or even the hot iron, without any response whatever. 
The loss <•! sensation may extend more deeply, so that the underlying 

1 Hysterical girls and women occasionally evince a depraved appetite, eating 
all sorts of extraordinary things. The school-girl habit of eating slate-pencils is 
mi example of tin-. I have personalty observed this evidence of hysteria on 

I I i:t 1 1 \ .M<.i~i..ii~. A young l.i'K recently under treatmenl ate enormous quantities 
of nutmegs. The rbid appetite of pregnancy is probably an hysterical dis- 
order. 

2 Traite Clinique et Therapeutique de l'Hysterie, Paris, 1859. 



HYSTERIA. 373 

muscles may be utterly without sensation. Tins peculiarity probably ex- 
plains the insusceptibility to pain spoken of by ( aire de Montegeron. The 
Jansenists or Conyulsionnaires "became so wrought up. by religious ex- 
citement that they fell, twenty or more at a time, into violent convulsions, 
and demanded to be beaten with huge iron-shod clubs, in order to be 
relieved of an unbearable pressure upon the abdomen. One of the bro- 
thers Marion felt nothing of the thrusts made by a sharp-pointed knife 
against his abdomen." 

Not only may there be analgesia, but loss of appreciation of heal or 
cold, and the surface may become blanched and white, and the -kin even 
bloodless. Brown-Sequard has demonstrated the absence of blood; a fact 
which has an historical interest in connection with the tests of the early 
religious enthusiasts. Charcot alludes to the epidemic of St. Menard, 
when the cut of a sword failed to produce any flow of blood. The tem- 
perature of the anaesthetic spot is sometimes lowered two or three degrees, 
and varies in different regions. There may be anaesthesia of the mucous 
membranes of the mouth, the pharynx, and larynx; or the organs of spe- 
cial sense may be implicated, and a resulting amaurosis, amblyopia, or deaf- 
ness ensue. In a paper upon "Hysterical Affections of the Eye," by Dr. 
Geo. C. Harlan, 1 of Philadelphia, attention is directed to retinal anaesthesia 
and various hysterical disorders of an interesting character. 

"Almost any derangement of vision may be counterfeited. A little girl 
of eight years complained that every object that she looked at seemed 
covered with diagonal white lines, the direction of which she indicated 
with her linger. As the ophthalmoscope revealed a normal fundus, a 
favorable prognosis was given. This was made more positive the next 
day, when the white lines changed to blue, and was justified by the early 
disappearance of the difficulty. 

k< In the second class of cases we have more or less retinal anaesthesia, 
with anomalous and variable symptoms, changing, perhaps, at each exami- 
nation. 

••In the third class of cases the parts affected have been the retina, the 
muscle of accommodation, the external muscles of the eyeball, and the 
elevator of the upper eyelid. 

•• It is not very uncommon to meet with patients who have apparently 
perfect cxi's and full acuity of vision, but who say that the test letters be- 
come blurred and unrecognizable after they have looked at them for a few 
seconds. That this is due to an exhaustion of the sensibility of the retina, 
which disables it from the sustained performance of its function, and not 
to an irregular action of the accommodation, is shown by the fact that it 
persists when the eye is fully under the effects of atropia." 

Taste and smell are sometimes impaired, SO that there is a greater or 

less extensive loss or a perversion, the patient declaring that natural odors 
are reversed, or that articles of food are tasteless. 



Phil. Med. and Surg. Hep.. AugUSl 12, 1876. 



37-1 CEREBRO-SPINAL DISEASES. 

The motorial symptoms arc numerous, and may be either of a sthenic 
or asthenic character. The simplest include spasms, violent gesticulations, 
and contractures : the more obstinate, paralysis of either a hemiplegic, 
or paraplegic, or even a local form, and chorea and convulsions, as well as 
various kinds of muscular incoordination. The individual may assume 
the most painful positions, the limbs being rigidly Hexed or extended, and 
the face distorted by grimaces of the most absurd description. Sometimes 
there is torticollis, or spasm of some small group of muscles, or the muscular 
rigidity may even amount to opisthotonos, pleurothotonos, or emprosthotonos, 
and these forms of trouble are much more marked in conditions of hystero- 
epilepsy and hystero-catalepsy. The dependence of these motorial pheno- 
mena upon reflex excitement is their marked feature, slight peripheral 
irritations, uterine trouble, or sexual excitement of any kind, often being 
the origin of the affection. 

The pharynx, larynx, and not rarely the stomach are implicated, so 
that difficulty of swallowing, loss of speech, and vomiting are resulting 
phenomena. Hysterical attacks of a convulsive character are met with 
sometimes, when the patient is apparently unconscious, but is in reality 
not at all so. There is slow respiration, which is scarcely perceptible, and 
small weak pulse. The legs and arms may be wildly thrown about, or 
rigidly extended, and there may be opisthotonos, while the skin is livid, 
and maybe bathed in perspiration. A lighter grade of attack is frequently 
seen, in which the patient, after a period of excitement, screams, and falls 
to the floor (being very careful not to hurt herself); her muscles become 
contracted; -he breathes heavily, froths at the mouth, talks incoherently, 
and berates those about her. She may cry, and in doing so sobs violently. 
sometimes catching her breath in an alarming manner, frightening her 
attendants and attracting sympathy. If left to herself and not noticed, 
-he may fall asleep or gradually recover. The patient looks about the 
room during the attack, and is undoubtedly conscious of what transpires. 
One significant mark of hysteria, previously alluded to. is that, however 
much the patient throws herself about, she is always careful not to do her- 
self injury. Pomme 1 was among the first to describe hysterical contrac- 
tures, and later Gorgel related a case of hysterical flexion of the thigh 

upon the pelvis which was supposed to be due to COXalgia. In hemiplegic 
contractures the upper limb may be drawn in to the trunk, the forearm 
18 flexed at ;i right angle, the thumb is bent so (hat the point is buried in 
the palm of the hand, and it is covered by the other lingers. 

According to Strauss, 9 extension of the upper limbs is quite rare. The 
lower limb is extended, bo that the foot presents the appearance of talipes 
equinus, the toes having a claw -like appearance. The thigh is extended 

on tic- pelvis, and tin- whole limb is addneled. 

Hysterica] contractures of a permanent character may affect the body, 



1 Ti-.iiie dea Affections Vaporeuses. 
I >' ia ( Contractures. Paris, 1875. 









HYSTERIA. 375 

cither laterally or below the waist, or but one member may be involved. 
Charcot 1 relates a ease in which the left leg was firmly extended. The 
foot presented the deformity of talipes varus, and the limb was very rigid, 
so that, by lifting it. the body could be moved without bending the knee. 
The contracture could be overcome by chloroform, but returned when its 
effects had disappeared. In this case the limb was agitated by a tremor, 
or •• treniulation convulsive." as this author calls the movement. These 
hysterical contractures often last for years, and are cured spontaneously. 
Skey a relates a case which is quite interesting. 

"In the year 186 1 a young lady of 1 6 years of age was placed under my 
care under the following circumstances: For eight months prior to her 
visit to me, she has been suffering from inversion of the left foot, which 
was so twisted as to bring the point of the foot to the opposite ankle ; in 

fact, at nearly a right angle with the toot of the opposite side. Her fam- 
ily consulted a surgeon of much experience in the treatment of distortion, 
and of orthopaedic notoriety. The case was considered as an example of 
an ordinary distortion, ami the foot was placed in a very elaborately made 
foot-splint, by the force of which it was made to approach a parallel rela- 
tion to the opposite side; but it was an approach only, for no mechanism 
could retain it in a perfect position, the toes yet to some degree pointing 
inwards. A month elapsed, and the disease continued unchanged. A 
second orthopaedic authority was then consulted in conjunction with tic 
first, and as no new light was thrown on the disease by the combined 
opinions of the two, the same principle of treatment was recommended to 
he continued, and tin 1 mechanism was yet somewhat more elaborated, and 
thus the eighth month of the young lady's life passed away, during which 
no constitutional treatment was resorted to, and loss of exercise, for she 
walked, it was almost unnecessary to say. with great difficulty." 

Skey examined the foot, and arrived at the conclusion that the inversion 
was too great to be due to the muscles alone, and discovered that those ,,f 
the whole limb were involved; that the disease had appeared suddenly in 
a girl of 1 •"» years, who was otherwise well and strong, and in whom there 
was no indication of acute local disease. 

The apparatus was removed; a hearty diet, with tonics, was ordered; 
she was told to walk; and at the end of six months was invited to a 
ball, her foot being still deformed. She accepted an invitation to dance, 
and remained standing throughout the entire evening. She had been 
suddenly cured. 

Hemiplegia and paraplegia of an hysterical character are sometimes met 
with, as well as local paralysis, but the face is rarely affected in hysterica] 
hemiparesis, and the tongue never so. 

The walk is quite different from that of organic hemiplegia, and accord- 
ing to Todd the foot is -imply dragged along and not swung, and there i-> 
an absence of that helplessness which is so characteristic of the serious 
trouble. Electric sensibility and contractility are not usually affected, 
though the former may be occasionally impaired. The cure is Spontane- 

1 ()[>. tit., p. S07. Hysteria, etc. London, 1866. 



376 CEREBROSPINAL DISEASES. 

ous, and there is never atrophy or any of the peculiar tissue changes or 
neuritis which generally follow hemiplegia from cerebral diseases. Para- 
plegia of the hysterical variety is rarely attended by any urinary or 
rectal troubles, and never by incontinence, and the muscles are well nour- 
ished and respond to electric stimulation. Some voluntary motion is 
possible in the recumbent position, and it is only when the patient walks 
that she shows her loss of power. Reynolds states that a peculiarity of the 
disease is the fact that no amount of help can keep the patient from stag- 
gering or falling; she may be supported by strong arms, but she sinks to 
the ground, not, however, falling entirely, but regaining her position by a 
voluntary effort. 

The visceral troubles are a host in themselves. Not only may the 
patient complain of unbearable pains situated in the liver, stomach, and 
other organs, DUl there may be urinary affections of considerable impor- 
tance. Two varieties of hysterical urinary derangement are spoken of by 
Charcot, one being ischuria, and the other a complete suppression, which 
he has called oligurie. In both cases the urinary passages are perfectly 
normal; in the first there is simple retention of urine in the bladder; 
and for a long time (amounting even to months or years) it will be found 
necessary to use a catheter. 

Laycock 1 has called attention to this state of affairs, which lasts 
sometimes twenty-four or thirty-six hours, during the menstrual epoch. 
Charcot has found the condition to last even longer — sometimes for several 
days. This suppression of urine is occasionally accompanied by vomit- 
ing, and the presence of urea has actually been discovered in the vomited 
substances. This has been explained by the experiment of Brown- 
Sequard, who found that after certain forms of mutilation carbonate of 
ammonia or free urea, was found in the intestines of animals, which settled 
the fact thai there was a " supplementary elimination." This same con- 
dition of affairs is not unusual in renal disease, and the odor of the 
breath and sweat is decidedly uriniferous. Vomiting of fecal matter is a 
rar<- symptom. There is in the majority of cases a decided increase 
in tin- amount of urine voided. If 18 of a very light color, quite limpid, 
and of low specific gravity, and is sometimes discharged during the con- 
vulsive Beizure. Digestive disturbances, accompanied by eructations of 
wind, borborygmi, epigastric pain, and Loss of appetite, are present in 

m08l cases. 

Abstinence from food and continued unconsciousness need hardly be 
: 1 1 1 1 1 < 1 < • < 1 toin this chapter. Cases of this kind derive sensational impor- 
tance from newspaper description, and from their very hysterical nature 

-ii'j'j<--t fraud and deception. The case of Louise Laleau. as well as 

others, has been cleverly investigated, and is doubtless familiar to my 
readers. The history of this class of cases furnishes us with many exam- 
ples, BOme of which are quit? ancient. 

1 Treatise on the Nervous Diseases of Women, London. 1840, u. 229. 






HYSTERIA. 377 

Senneratus 1 writes of three individuals who fasted almost two years, 
and "yet, though lean, were in good health." 

LJpoD the authority of Schenck, 2 we are informed thai "Katherine 
Binder, a native of the upper Palatinate in Germany, was said to receive 
no other nourishment than air tor more than nine years. John Caffimer, 
in the year of our Lord L585, commanded her to be watched by a Minis- 
ter of State Ecclesiastic and two Licentiates in Physic, but they could 
make no discovery of her being an impostor, and therefore reported it to 
be miraculous." 

A symptom which I am inclined to think very common, but which is 
not generally considered so, is the globus hystericus. The patient calls 
attention to a -Tumi) which rises in her throat." It is probably nothing 
more than a spasmodic contraction of the muscles of the pharynx or oeso- 
phagus, or in other cases a morbid, sensory disturbance. It "rises" from 
the epigastrium, and is attended by dyspnoea and difficulty in deglutition. 
In -one' cases obstinate vomiting, which is readily excited by such Blight 
agencies as a hand laid upon the surface of the body, or the administration 
of a very small amount of food, is a formidable symptom, and unless cor- 
rected the patient may become speedily exhausted. In one case which 
1 saw at the request of Dr. Austin Flint, this condition had lasted for 
Beveral years, and was not relieved by any medication, but was for a 
time stopped by pressure made over the left ovary. 

The disease among males is of interest because of its rarity. -V case 
presented by Bonnemaison, 3 of Toulouse, may be cited: — 

The patient was a man aged 72. The brother of the patient was a 
hypochondriac; and his mother, who died at the age of SI. Buffered from 
various forms of nervous disturbance, analogous to those of her hysterical 
BOn, after reaching her 76th year. The attacks in the case of Dr. Bonne- 
maison's patient came on three or four times in the twenty-four hours; 
ushered in. when occurring during the night, by nightmare: when in the 
day. by various sensations, and usually by pain in the epigastric region. 
An aura proceeding from this point travelled along the sternum to the 
throat, and thence to the mouth and tongue, and other regions of the 
body, the muscles of the parts affected by this sensation being thrown into 
violent, rapid, and unaccountable convulsive action. The patient uttered 
strange cries and yells, or repeated the same words over and over again 
with extreme rapidity. At times the tongue would be smacked violently 
against the roof of the mouth, the cheeks spasmodically puffed out with 
the action of blowing or whistling, and the jaw - -napped violently together, 
without, however, biting the tongue. The arm- were moved rhythmically 
together with the action of living, or drumming, or playing the piano. 
Sometimes the lower limbs shook violently, or executed the movements 
of dancing. The attacks bore a strong resemblance to those of the "con- 
vulsion n aires" of St. Medard, or the rhythmic chorea of the epidemics of 
Louviers, Toulouse, and Morziac. The disturbance of the voluntary mus- 

1 Prax. Med., p. 212. ■ Obs. 1. S, p. 

Archives G enemies de .Med., dan. 1875. Abst, in Med. News. Oct 18* 



oiS CEREBRO-SPINAL DISEASES. 

clea might be accompanied by spasm of the involuntary muscles also, or 

the latter might form the chief phenomena of the paroxysm, consisting in 
hiccup, eructations, sighs, and borborygmi. During- the whole of the at- 
tack the hyperaesthesia of the skin was excessive, especially at the tore- 
head, epigastric region, and sternum; there was no loss of consciousness. 
The attack ended either with a copious how of limpid urine, or a discharge 
of tears. There was never any pain or sensation referable to the genera- 
tive organs, nor anything whatever in the history or the symptoms indica- 
tive of their implication in any way whatever. The same absence of any 
pathological condition of the organs of generation has been observed in 
cases of male hysteria observed by others. 

Causes Hysteria is most decidedly an affection of women, and is 

Connected in many instances with some sexual or uterine derangement. 
Among men hysteria is far less rare, I think, than it is supposed to be, 
hut witli them the hysterical trouble is of a lighter grade, and it is unusual 
for examples either of anaesthesia, convulsions, or contractures to be wit- 
nessed. As a rule, the hysterical man possesses a smooth face, slender 
figure, soft falsetto voice, large thyroid cartilages, small hands, and taper- 
ing lingers, and sometimes large mammae. His genital organs are poorly 
developed, and his manners are mincing and effeminate. Hysterical 
phenomena are, however, not uncommonly presented by stalwart men. 
Among women this approach to the appearance and behavior of the other 
sex is inconsistent with the development of hysteria. Women with bushy 
eyebrows, coarse hair, perhaps a slight moustache, angular build, narrow 
hips, and coarse voices are seldom hysterical. They are •• strong-minded, " 
rarely emotional, and inclined to look upon the hysterical trouble of their 
weak sister- with something like contempt. 

Reynolds aptly says: '* Some women are as little likely to become 
hysterical as some men are to fall pregnant." It might be added : and as 
their chances to conceive are diminished. Hysteria is of much more com- 
mon appearance among spinsters and single women, and is far from being 
rare among old maids who marry late in life. A case of this kind fell 
tinder my observation some years ago. An examination revealed an un- 
developed uterus; and from the nuptial night dated a series of nervous 
symptoms of a grave hysterical character. The uterine irritability which 
tmected with the pregnant slate between the ages of thirty and forty 
ie apt to produce a profound impression upon the nervous system. Among 
married women with impotent husbands, or among those who have, on the 
other hand. Buffered through the lust, inconsiderat ion, ami brutality of 

husbands of another kind, the disease is not uncommon. The puerperal 
-iair. lactation, ami the cessation of the catamenia favor its development. 

I have lately treated a number of cases of a class which I am sure i> 

familiar to most medical men, especially t<» those who devote the greater 
part "t their time to the studj of nervous disease. I allude to certain ill- 
defined hysterical conditions that are connected with or follow the puer- 
peral state. These cases do not come under the head of puerperal mania, 
winch if a common and well-recognized form of insanity, but are difficult 



HYSTERIA. 379 

of description and classification, because of their irregularity. The 
patients I have seen have all beenuraemic al Rome time during pregnancy, 
not to the extent which is accompanied by convulsions or other grave 
symptoms, but the blood-poisoning was much more extensive than it 

usually is. Barker thinks that albuminuria is not the cause of puerperal 
mania, hut. when found, is merely a coincidence. In the cases I allude 
to it was always present, and seemed to he the cause. I have seen the 
same symptoms expressed, though in a Less marked degree, in patients who 

Were suffering from chronic nephritis, and where the puerperal Btate had 
nothing to do with the history. 1 

In the spring of 1875 Mrs. C. came to my office with her husband. I 

found her to he an amiable, well-educated woman of thirty-two years of 
age : her manner was cheery and agreeable, and there was no evidence of 
menial trouble. Three months before this she had been delivered of a 
child at full term, which was born dead. A week after her milk •• dried 
up." The last months of her pregnancy were attended by evidences of 
unemia, marked anasarca, clouded urine excreted in small quantity, but 
no convulsions or mania. Mrs. C.'s previous history was uneventful. 
There was absolutely no hereditary predisposition to insanity, and her 
mind was perfectly clear during pregnancy. 

She was anaemic, and complained of dizziness, palpitation, gastric dis- 
turbance, vertical headache, loss of memory, ringing in the ears, etc. She 
passed her urine at the time of her visit in norma) amounts, and it did not 
contain albumen. Her complexion was pale, and her pupils were dilated. 
A very slight blueness of the skin was apparent, hut was confined to the 
hands. The lips had not lost their lines of expression, which is generally 
the case in melancholia, and they were not swollen. She was inclined to 
sleep. Considering that the symptoms indicated "cerebral ana-mia." I 
began with iron, phosphorus, and other remedies of the same kind. 

Two days after this visit she again appeared at my office, looking much 
agitated, and saying that she had come for "protection from herself." 
She had been tempted to get up from her bed and cut her throat with her 
husband's razors. She was perfectly cognizant of her condition, and was 
aware of the fearful nature of the act she was tempted to perform. After 
a talk of half an hour, she left me, feeling settled, and without the desire. 
On another occasion she came to set me. as "she had the feeling again." 
She had taken her sister's baby in her lap. and while it was (here she 
••suddenly felt like throwing it on the floor' 1 with all her force. At 
another time she was prompted to run the blade of a pair of scissors into 
the fontanelle. These impulses would recur every week or BO, when >lic 
always came to see me, ami would sit a few minutes, talk upon other Bub- 
jects, and rise to go, saying: "Now, doctor, the feeling has passed off." 
Not at this time, nor at any other, were there delusions of any kind. 

I'mler treatment she improved in general health, and her nervous symp- 
toms disappeared. 

Her lasl morbid impulse occurred during the fourth month after treat- 
ment. One evening, with her husband and brother, she went upon the 
house-top to see a tire. While there the old feeling returned, and -in- 



B —'ii Med. and Surg. Journ.j dune US, 1876. 



380 CEREBROSPINAL DISEASES. 

would have thrown herself from the roof, had she not been prevented. This 
was the last and most serious expression of the disease. Since that time 
she has not had a return, and says she is perfectly well. 

A Becond case I lately saw was attended by slight though perfectly de- 
fined mental changes. The patient was a young married woman of 
twenty-four years. For some time before parturition and during her 
pregnancy there was kidney trouble. Before her labor she was a. loving 
and devoted wife, but shortly after lost all of her amiability, and treated 
her husband and mother with marked coolness, and sometimes with de- 
cided rudeness. A month after delivery she took a deep interest in 
religious matters, ami carried the observance of her religious duties to 
such a pass as to be disagreeable to all about her. She did eccentric 
tiling-, sueh as getting up at night, going down to the piano in the draw- 
ing-room, and singing hymns. When reminded of the unseasonableness 
of the hour, she would return to her bed, first shutting the hymn-book in 
a mechanical manner. 

I saw her in this condition, and found a state closely bordering on 
melancholia, though there was no mental depression, no anxious facies, 
no sighing, no hopelessness. A persistent use of agents which would 
restore the action of the kidneys, combined with fresh air and a well-regu- 
lated diet, did her much good. After a few weeks the patient slept well, 
and the mental irritability gradually disappeared. 

In both of these cases there were symptoms which were not those of 
insanity. In Case I. the patient was able to reason, and had full con- 
sciousness of her infirmity; so that she had the power to seek the society 
of Others when she felt the impulse. There was the absence of all physi- 
cal signs of insanity, except the coloration of the skin. In the second 
case, the short duration of the mental trouble, and its subsidence with 
improvement of the kidney difficulty, proved it to be a functional de- 
rangement. 

A- n gardsage, hysteria rarely begins before the twelfth year; it generally 
takes its origin at the time of puberty, ami from this period may continue 
through life. It not rarely begins after marriage, or sometimes not until 
alter the menopause, but this is exceptional. In males it begins in middle 
life, though I have seen the alfection among boys. Hysteria, is not ne<-es- 
sirily a disease of the well-tO-do, though indolent habits and luxurious 

livingfavor its development ; but it frequently appears among overworked 

shop-girls who are Compelled to Stand for many hours during the day. 
The lollies of fashionable life have much to do with the production of a 

morbid performance of functions of the nervous system. Continued rounds 

of dissipation, parties and balls which do away with sleep, together with 

excitemenl ami late suppers, days of idleness spent in reading French 
novels and eating improper food, or tippling Liqueurs, especially favor the 

developmenl of this morbid slate. This mode of life, when kepi up for 

Rome time, especially when the 1 menstrual periods are disregarded, brings 
nboul h condition of erethftm which expresses itself in the symptoms I 

have named. I K-iimnonliu a mav be alien. led b\ attacks of this kind, 

and so tnai menorrhazia, but main cases occur even when there is no dis- 



HYSTERIA. 381 

turban ce of menstrual function. Abnormalities of the position of the 
uterus, and excessive sexual excitement, whether from masturbation or 
coition, have decided etiological bearing, while warm weather favors the 
development of attacks. Mental worry, emotional excitement, an attack 
of illness, and a number of influences of the same kjnd all act as exciting 
causes. 

Morbid Anatomy and Pathology Accidental lesions are some- 
times found, but so irregular is their character that they art.- valueless as 
indications. 

As to the pathology of the affection, very little can be said in addition 
to what has already been stated in speaking of the symptoms. Hysteria 
may be said to be a very near relation to insanity. Hammond even con- 
siders it a form of insanity ; but 1 should be loath to believe that so many 
people are actually insane. Hysteria is rather a mental incoordination. 
Emotional exaltation, connected with liveliness of ideation ami with feeble 
volition, and a paralysis of judgment, maybe said to be the mental condi- 
tion of an hysterical patient. The balance is losl ; and when tin.' emotional 
side has full play, all the reflex and sensational functions are active and 
unchecked, while it is only with difficulty that the governing Bide to which 
belong volitional and intellectual control is made to counteract the other. 
This is only brought about by the most powerful agencies, and sometimes 
these are inefficient. If the reader will consult an article bv Lauder 
Brunton, 1 in one of the West Riding Reports, he will find some excellent 
diagrams which illustrate the mechanism of the nervous centres in the 
physiology of inhibition. 

I have slightly modified the chart of this author by introducing another 
centre. Let Fig. 4G represent the arrangement of nerve centres concerned 
in the performance of the functions of the cerebro-spinal system. I indi- 
cates the centre of ideation, E an emotional centre, W a will centre. M 
a motor centre innervating; m (a muscle), v (a vessel), and <; (a gland . 
S is a sensory centre, and P the origin of an external impression. The 
connecting lines are efferent and afferent nerves. It will he seen that I is 
in centrifugal communication with W, with M, S. and with E. So that 
ideas which are evolved without external stimulus may find motor expres- 
sion either in a voluntary or involuntary manner: may atl'ect tin' emo- 
tional centre, or may be stimulated by impressions received either from 
that centre or from S. External impressions may be transmitted from P 
either to S, to E, or to M ; in one case being perceived and transmitted 
to a higher centre, or being converted into a reflex action. E is affected 
by S mid by I, and in turn influences M and I. and to a slight degree W ; 
Or on the other hand may be controlled by AV. In the normal -late we 
may roughly suppose the proportions of these areas to be represented in 

the right-hand diagram. In the hysterical Maic their relative (left-hand 

diagram) size is greatly altered; E gain- in size, and W is \n\ much 



West Eliding Lunatic Asylum Reports, vol. iv. p. 17:>. 



382 



CEREBROSPINAL DISEASES. 



diminished. The relative size of the communicating tracts also under- 
goes modification. Though this explanation is decidedly rough and super- 
ficial, I trust it will give the reader a better idea of the pathology of this 
affection than would any extended written description. 



Fig. 46. 





w 




— * — 


1 
I 


1 


\ 


"\ ' 


VI 


\\ 


EK m 




s 


ET 


\^ > 


•r 



The Pathology of Hysteria. 



Diagnosis — As hysteria may counterfeit nearly every known symp- 
tom, it will be seen that the task of making a diagnosis is not always an 
easy matter. If. however, we consider that the symptoms are generally 
presented in a group, which is cjecidedly irregular and inharmonious, and 
thai the patient is on the alert in regard to all thai goes on about her; 
that Bhe lias a fear of severe treatment; that the use»of chloroform will 
certainly overcome the contractures ; and that the cure is generally sudden, 
there is not much chance for mistake. Besides, there is never any evidence 
of gross organic change, the muscles only losing their fulness from inaction. 

Prognosis. — If the individual has suffered for a great length of time, 

and especially if there be Confirmed uterine disease, the chances of entire 

recovery will be extremely had. The disease is not only discouraging 
in the way of treatment, but annoying to the friends, and far more disa- 
greeable to the physician, who receives very little for his pains hut abuse 
and \\:int of appreciation. Some cases may be easily cured, and these 
are among young people. Much, however^ depends upon treatment. 

Treatment. — The history of the treatment of hysteria is curious in 
the extreme. Going back to the middle ages we find numerous examples 
nt' miraculous cures, which were undoubtedly of an hysterical character. 

Scheie de Vere, in his little work entitled kk Modern Magic." thus speaks 

of a favorite mode of treatment which has been followed by the Zouave 
Jacob and many others in modern times: — 



HYSTERIA. 383 

" The imposition of hands for the purpose of performing miraculous 
cures has been practised from time immemorial ; Chaldees and Brahmins 
alike using it in cases of malignant disease. The kings of England and 
of France, and even the counts of Hapsburg in Germany, have been 
reputed to be able to cure goitres by the touch of their hands. The idea 
seems to have originated in the high North, King Olave the Saint being 
reported by Snorre Sturleson as having performed the ceremony. From 
thence, no doubt, it was carried to England, where the Confessor Beems 
to have been the first to cure goitres." 

" In more recent times a prince. Hohenlohe, in Germany, claimed to have 
performed many miraculous cures, beginning with Princess Bchwarzen- 
berg, whom he commanded in the name of Christ to be well again. Many 
of his patients, however, were only cured for the moment. When their 
faith, excited to the utmost, cooled down again, their infirmities returned. 
Still there remain facts enough in his life to establish the marvellous 
power of his strong will, when brought to bear upon peculiarly receptive 
imaginations and aided by earnest prayer." 

Several years ago an individual named Newton went about the country. 
It was his custom to hire a large hall and extensively advertise. Upon 
the day appointed he would meet the lame, halt, and blind, and after 
powerful exhortations and prayers, tell them to form in line ami pass one 
by one before him. The emotional excitement and eager anticipation 
were sufficient in some instances to divert the hysterical patients who 
chanced to be among the number, so that in many instances there were 
spontaneous cures, the lame dropping their crutches, and starting off at a 
lively gait, and the blind recovering their sight. 

Dr. G. M. Beard, in an entertaining paper upon "Mental Therapeu- 
tics," recently called attention to some experiments he had been making. 
In many instances of functional disease, he assured the patients that their 
recovery would take place in some very short time, and found that at the 
time specified they returned completely cured. This procedure in cases 
of hysteria is of great value. I have repeatedly stopped an hysterical 
attack by a douche of cold water or by the exhibition of the cautery. 
Oftentimes, after the patient has been pleaded with, threatened, ami dosed 
to no effect, a sudden fright or a sharp word or two will do more for her 
than anything else 1 ; but t he physician's demeanor to his patient should 
always be characterized by firmness and dignity, and not by harshness ov 
undue >e\ erity. 

A- to medication, we may make use of the motor-depressants, bromide 

of sodium. Iiyoscyamus, or the mono-bromide of camphor, in doses »'t' three 
grains r\rv\ hour, till quiet 18 obtained; the spts. etheris CO., chloroform 
or chloral, and valerian, or its compound, valerianate of zinc (IT". .">. I. 
23, •'>*. 53, 54, 55, 87). The obstinate vomiting is occasionally stopped 

by hypodermic injection- of morphine; and a belladonna plaster over the 

irritable ovary will often prove to be an excellent form o\' treatment. 
For the anaesthesia and paralysis, strychnia ami electricity are the best 



3S4 CEREBRO-SPIXAL DISEASES. 

remedies which I know of, the latter being employed in its induced form, 
ami the electric brush applied upon a dry surface. General treatment of 
a tonic character should be used when it is possible; and iron, in combina- 
tion with phosphorus or phosphoric acid, cod-liver oil, and sea-baths 
( IF. 8, 9, 1<>. 12. 24, 57, 32), together with local treatment. Local dis- 
ease should be promptly eradicated if possible, uterine versions or flexions 
righted, and the menstrual function restored to its regular character. 
In those bed-ridden cases which are so discouraging and trying, we may 
use Weir Mitchell's treatment. A patient may lie in bed leading a very 
irregular life, and doing just about what she chooses, without improving 
in the least; while, if her room be darkened, her diet changed, and her 
muscular tone kept up, a cure may be often wrought. 



HYSTERO-EPILEPSY. 

This interesting variety of hysterical trouble has received a great deal 
of attention from Charcot, 1 Dunant, 2 Dubois, and Bourneville, as well as 
from many other writers, some of whom did not recognize its distinct 
character until after Charcot's valuable investigations had been announced. 

Tis>ot :! says that "the hysterical attack sometimes resembles epilepsy, 
so much so as to have received the name epileptiform hysteria, but the 
attack nevertheless does not possess the true character of epilepsy." 

Others, among whom are Briquet, 4 Landouzy, and Saunders, have also 
described the condition. 

Upon the authority of Charcot, 5 the combinations of epilepsy and hys- 
teria take place under the following different circumstances: — 

1. a. Epilepsy being the primary disease, upon which hysteria is en- 
grafted, under the influence of emotitmal Causes or at the time of puberty. 

h. After marriage (vide Landouzy's Case), the epilepsy having always 
existed. After connection, the hysterical feature of the attack is developed. 
In this case the hysterical character of the epilepsy subsided when sexual 

excitement was interrupted by pregnancy. 

2. The hysteria being primary, the epilepsy is added thereto. A rare 
condition. 

;;. Convulsive hysteria coexisting with petit-mal. 

1. An epileptic attack, followed by hysterical contractures, anaesthesia, 

e|c. 

I have observed a form which slightly differs from any of the above. 
The patient, an epileptic, was seized occasionally with hystero-epileptic 
attacks during the mensirual periods, and at other times there was un- 
complicated epilepsy. She has had epilepsy since the fifth year, when 
-he was frightened i»\ her mother, who threatened to beat her. 

1 Leconssurles Maladies du Systeme Nerveux, pari i., Paris, is?--'. 

■ De I'Hystero-epilepsie. :t Maladies des Nerfs, quoted by Charcot. 

1 I »p. .it. r> Op. cit., p. 824. 



I 



IIYSTERO-EPTLEPSY. 385 

Symptoms. — I may illustrate the course of the affection by the rela- 
tion of two personal cases: — 

Case I A. P., aet. IK, since the beginning of the menstrual epoch. 

has suffered from her present form of hystero-opileptie attacks, which 
have come on generally just after the cessation of the catamenial period. 
She has been very irregular, and has suffered from amenorrhoea, hut there 
is no uterine disease that I can discover. This amenorrhoea has amounted 

to an entire cessation of the menstrual flow for Bevera] months at a time, 
during which she would have her attacks. Some of these attack- wen- 
like that I shall presently describe, and lasted for Beveral days. There 
was no succession of attacks, hut usually several severe hut distinct epi- 
leptic seizures, and afterwards an hystero-epileptiform paroxysm. She 
had heen in the Epileptic Hospital for some time, and had given a great 
deal of trouble by her irritability and mischief-making propensities. Her 
attacks at the hospital were three in number during one year, each of 
them lasting from two to three days at a time, during which there were 
suppression of urine, vomiting, and hemianesthesia, which in one instance 
was on the right and twice on the left side. 

Her most pronounced attack occurred while she wa> staying at her 
mother's house, where T was summoned to see her. This was on the 11th 
of .March, 1877, when her mother came to my office, and told me that her 
daughter had been ill since the preceding Thursday; that she had gone 
with her sister to see a friend ; and that while there she had heen seized 
with a severe fit, and could not go home until the next day (March 9). 
She said that on her return her daughter complained of headache, pain in 
the back, over the ovaries, and abdominal discomfort, and as the time for 
her menses had come, she gave her a pill of aloes and myrrh on Saturday, 
and another on Sunday night, with no result, and a warm hip-hath on 
Monday. (She had not menstruated since December. 1876.) On Mon- 
day she had several severe epileptic fits, with frothing at the mouth, during 
which she bit her tongue, and went to bed. where she remained until 1 saw 
her. I went to the house, and found that she had been seemingly uncon- 
scious since Monday night, that she had been "frothing at the mouth" 
since that time, and that on Tuesday she began to mutter and talk to her- 
self; that she had had hallucinations and delusions, some of them of a 
painful character, believing that she had been followed by a nurse from 
the hospital, whose intention was to kill her. When her mother entered 
the room, she berated her soundly, and was quite abusive, indulging in 
obscene language. 

1 found her lying upon the bed. lightly covered by a sheet. The muscles 
of her back were rigidly contracted, so that her position was one of opis- 
thotonos; her head was turned to one side, and her tongue was protruded. 
Her rvis were open, and the pupils widely dilated, and insensible to light. 
Her expression was blank, and -he was apparently unmindful of her sur- 
roundings. Her arms were drawn over her che-t, and her forearms 
slightly flexed and crossing each other. Wrv thumb- were brut in. and 
covered by her other linger-, which were rigidly flexed. Her pulse was 
12 1 ; temperature I'M. 2 ; respiration 35. Shewn- muttering to herself a 
disconnected string of words without any meaning, and continued them 
during mv visit. She had not eaten for t w enty-four hour-, and I ordered 
milk and chloral hydrate in twenty-grain doses, to lie forced into her 
mouth it' -lie did not open it <>\' her ow n accord. 
25 



3SG 



CEREBROSPINAL DISEASES, 



On my return the next morning, the mother told me that she had had 
delusions during the night, and had cursed those of her family who ven- 
tured to approach her. 1 found that the rigidity of the previous day had 
become less marked, hut that her right hand and forearm were beneath the 
lower part of her back. The right corner of her mouth was drawn down- 
wards, and her eyes were still open, and the corneae anaesthetic. She did 
not know me. Temperature 100°; pulse 108; respiration 28. On the 
following morning Dr. Charles E. Loekwood of this city went with me to 
Bee her. She was then much better, and was less rigid, but the right 
hand was tightly clinched, and no persuasion would induce her to open it. 
Her toes were also flexed, and her right foot presented the appearance 
called by Charcot, "le pied hot hysterique." Her corneae were sensitive, 

Fisr. 4 7. 




Uystoio-Epilepsy. 



and her pupils less dilated. There was some rolling of the eyeballs from 
side to side, and the patient occasionally sighed. Her pulse was now only 
96, and was small and irritable ; the temperature was 99°. When sharply 
spoken to, she said " Doctor," and relapsed into a state of stupidity, turn- 
in- her head from right to left, and staring at tin; ceiling. She occasion- 
ally moved her tongue, as it' her mouth was dry. Dr. Loekwood suggested 

the experiment of frightening her, and so we threatened the use of tin' 

cautery, the mention of which first brought forth remonstrance and after- 
wards a reply to our questions. 

Her mother stated thai she had not passed urine for several days. I 

did not find a distended bladder, but when (he catheter was introduced, it 

brought awayaboul half a pint of light-colored urine. This suppression of 
urine continued for several days. 1 She arose from her bed the day after 
this last visit, :ii!<l her menses appeared. During the next three or four 
days there was -light hemianaesthesia of thi right side. 

Case II. — A young lady, 19 years old, had been my patient for nearly 
a year, during which she had had on an average about one attack of haut- 
ukiI in ;t week. Her epilepsy dated from the ninth year, and was not de- 
pendent upon any discoverable cause. At all times she is irritable, pettish, 
and techy, and leads a very irregular life. There was nothing remarka- 
ble about her attacks; they*were not very violent, nor were they connected 



J 



1 It i> probable that thi- urinarj derangement was of the form called by Char- 
cot oliguria. 



IIYSTER0-EP1LEPSY. 387 

with any hysterical manifestation. There was rarely any coma ; but the 
attacks were more severe about the time of the menstrual discharge, \\ bich 
was never abundant. On September 12, 1876, I was telegraphed for 
to see the patient. The day before my arrival, without any premonitions, 
she had had an attack very much like all the others, but instead of falling 
asleep she remained convulsed, and apparently unconscious. She vomited 
two or three times, and became quite cyanotic; so the local physician was 
sent for. He found it impossible at first to open her mouth to remove the 
substance which had collected therein and distended the cheeks, and it 
was only when he was assisted by others that he could do so. She was 
placed iii bed, and remained in this state, the eyeballs rolling from Bide to 
side, the body drawn slightly to the right side, and the hands clinched. 
She became delirious during the night, and had delusions of a lively kind. 
like those of a patient with delirium tremens. Outbursts of hysterical 
laughter and jactitations of the limbs followed in the morning, and then 
she became quiet, but the muscles were somewhat rigid. I arrived at 
about 2 P. M., and found her lying upon the bed with open eyes and 
meaningless stare. Her right arm was rigidly adducted, and the bed- 
clothes were tightly grasped in her hand. The head was drawn so that 
the chin was approximated somewhat to the chest. The teeth were Bel 
together, and there was some grinding of the molars. She breathed 
noisily, there being an accumulation of mucus in the throat. Temperature 
100.2° ; pulse 80. The pupils were dilated, and seemingly unaffected by 
light. Pressure upon the right ovary caused her to shrink somewhat. Her 
abdomen was distended by flatus. During the night she became somewhat 
relaxed, and muttered unintelligibly, but in a petulant tone. She fell into 
an apparent sleep about 5 A. M., her respiration being natural. She awoke 
at about 5 P. M. of the same day (the third), and though someAvhat fa- 
tigued, arose and went about. She was not hemianaesthetic, but ischuria 
lasted for several days. 

An inspection of the cases of Charcot and others will enable the reader 
to detect certain symptoms which are alike in all the patients. 

Case III Reported by Charcot. Marc , 23. Hystero-epilepsy 

dated from the lOtli year ; attended by hemianesthesia and hemi] aresia 
of left side. Daltonism of left eye ; frequent vomiting. Attack preceded 
by an aura and pain in left ovary. Attacks included three stages : </. 
Tetaniform contraction, epileptiform convulsions, b. Violent movement 
of trunk and lower extremities (period of contortion). Silly and discon- 
nected talking. Patient appeared to be semi-delirious, c. Laughing fits; 
attacks stopped by ovarian compression. 

(ask IV Charcot. Cot., 21 years. Hysteria dated from the loth 

year, and followed cruel treatment at the hands of her lather, when she 
took to drink and became a prostitute. Local symptoms are : right hemi- 
anesthesia - , ovarian pain, permanent, and tr emulation of the right low ei- ex- 
tremity. Convulsions followed ovarian pain ; they are tonic, and she bit 
her tongue and frothed at the mouth. The second period followed at 
once, and was marked. The attack often terminated by movements of 
the pel\ is, laryngeal constriction, crying attack, passage of large quantities 
of urine. Ovarian pressure moderated attack, hut tlid n»»t arre-t it. 

Cask V — Charcot. Legr. Ge*oe*vieve, 2s. Hysteria dated from 
puberty. Permanenl h»cal symptom; left hemianesthesia, ovarian pain, 

and mental peculiarities (bizarre). Aura quite marked, and BO are cardiac 



388 CEREBROSPINAL DISEASES. 

palpitation and head symptoms : attack may be divided into three stages: 
a. Epileptiform convulsion, frothing at the month, and stertor. b. Move- 
ment of limbs and body. c. Period of delirium, during which she detailed 
the events of her life. Occasionally last stage would be characterized by 
hallucinations, when she would see crows, serpents, etc. She would at 
other times dance. Ovarian pressure arrested attack. 

Case VI. — Charcot. Ler., 48 years. Attacks date from early life, 
when -lie was frightened by a dog, and by the sight of the body of a woman 
who had been assassinated. Local symptoms: hemianesthesia of ovary ; 
paresis and contractures of the upper and lower right extremities, and 
occasionally the left. Attacks begin by ovarian aura, followed by epilep- 
tiform and tetaniform convulsions, after which she assumed the most try- 
ing postures. At the time of the attack she falls into a delirium, during 
which she indulges in furious invectives, crying to imaginary persons: 
•• Villains, robbers, brigands! fire, fire! Oh the dogs! oh, I'm bitten!" 
these being suggested by memories of her childish fears. When the con- 
vulsive part of the attack is terminated, there follow: 1. Hallucination of 
sight, the patient seeing skeletons, frightful animals, spectres, etc.; 2. A 
paralysis of the bladder; 3. A paralysis of the pharynx; 4. Finally, a 
more or less permanent contracture of the tongue. These last symptoms 
remain for several days, during Avhich it is necessary to feed the patient 
with the stomach-pump, and then draw off her urine. 

Two cases, reported some years ago, 1 resemble the more modern hys- 
tero-epilepsy so closely that I am inclined to infer that they were attacks 
of this disease. 

Case VII Arguinosa's Case. Woman, twenty years. Epileptiform 

convulsions first showed themselves during infancy, in consequence of head 
injury. They reappeared at puberty. While residing in the house of Dr. 
Arguinosa she complained of ovarian pains. The precursory signs of an 
epileptic attack soon showed themselves, and. on returning from a walk, 
" she had scarcely time to throw herself on a bed before she lost both sen- 
sation and motion. The skin was hot, respiration loud, pupil immovable, 
eyelids closed convulsively, limbs flexible, while the lips were convulsively 
moved, or else a sardonic smile sat upon them. Bleeding was about to be 
practised, when, all of a sudden, after some horripilations, the skin became 
Cold and colorless, the pulse and respiration were suspended, and the 
patienl appeared dead." 

C.hl affusion to the head seemed to produce an effect. The respiration 

then became agitated, the pulse strong, and violent convulsions, with 
tetanic rigidity (pleurothotonos) set in. 

She became angry and irritable, screamed out. Noises in the room, 
light, and tin- BtepS of persons around her were siitlieient to "draw her 

from her attacks of delirium." She had a^resentiment of sudden death. 
"Two days following there were the same alternatives, tne delirium 
occurring less frequently, and lasting a shorter time; she slept but little 

thai night (the lth)j the next day the only symptoms noticed were aver- 
sion to water, light, and air^with the pain of stomach previously com- 
plained of. On the -i\ihvl:i\ Bhe asked for a bath, and the opium which 
-he took in the evening. A -tool brought on strong convulsions and noisy 



1 Forbes Win-low'- Psychological Journal, vol. ii. 



CATALEPSY. 389 

delirium. The women who were attending to her believing her to be pos- 
d by the devil, sprinkled her with holy water, which increased her 
furious eric- and bizarre contortions. The following night was dreadful; 
the mouth full of foam, the eyes injected, and the delirium almoBl continu- 
ous. About ten in the morning immoderate laughter succeeded the pre- 
vious symptoms. She ultimately died." 

Case VII Ward's case. Mary P., aged 13. Measles at age of seven, 

and has ever since been Bubject to cough and pain in the side. About 
one year ago she had her first epileptic tit, during which Bhe attempted to 
bite and -cratch the bystanders. She was not insensible, hut delirious. 
The attack- came on at intervals tor a fortnight afterwards, and they he- 
came much worse at the end of this time. Her arm- were extended and 
rigid, and the fingers clinched. At o'ther time- she struggled violently, 
and the abdomen became swelled. She never became unconscious. Her 
disposition was changed, for she grew exceedingly mischievous between 
the attacks, developing a propensity for climbing trees and playing the 
hoyden. Ovarian pain sometimes. The attack is occasionally finished 
by a tit of laughter. 

Charcot holds that a very important diagnostic sign is the reduced tem- 
perature. In epilepsy the temperature may rise to 107. G° F., while that 
of the hystero-epileptic rarely attains a height of 100° F. In the cases I 
have alluded to, Case I. presented all the prominent symptoms by him 
enumerated, and still the temperature was quite high. 



CATALEPSY. 

Definition. — A disease closely allied to hysteria, of extreme rarity. 
and characterized by a condition of muscular contraction and semi-rigidity, 
so that the limbs may be placed in constrained and awkward positions. 
and remain so for some time. It is attended by loss of consciousness and 
cutaneous amvsthesia. 

Symptoms. — The disease, like epilepsy, is characterized by attacks 
separated by intervals of greater or less duration, during which periods 
the patient is usually in apparent good health. 

After such prodromata as malaise, vertigo, headache, or functional tre- 
mor, the individual will suddenly be seized. He may lie talking or eat- 
ing, when the particular act is arrested, the mouth remaining open, or 
the hand half raised. The muscles become rigid, but the limb may be 
moved by the physician or bystander, and if placed in a new position, no 
matter how awkward it may be, it will remain SO fixed until the muscles 
are fatigued, when it drops. Patients arc reported to have remained for 
e\ en an hour or two with legs or arms extended : and in one case 1 -aw the 
patient remain for half an hour with the right arm extended in a Straight 
line from hi- -boulder, and the other arm extended above the head. The 
position was subsequently changed. The peculiar semi-rigidity of the 
muscle- has gained for it the name flexibxlitOS cerea, on account of a 
"wax-like" mobility; ami there i- none of the pronounced -titl'ue--. OT, 00 



390 CEREBRO-SPINAL DISEASES. 

the other hand, limpness of the limbs that usually attends the unconscious 
state. The surface of the body becomes quite cool; the pupils are dilated ; 
respiration becomes shallow and scarcely perceptible ; and it is sometimes 
difficult to find the pulse, which becomes thready, but nevertheless pre- 
serves its regularity. 

The skin is anaesthetic to an astonishing degree. Needles may be 
thrust into the tissues without the knowledge of the individual, and pinch- 
ing, ^lapping, or other forms of cutaneous stimulation produce no expres- 
sion of pain. In a case of hystero-catalepsy, seen with Dr. D. B. St. 
John Boosa, I repeatedly thrust pins into the arms and legs of a young 
woman and watched attentively for some sign, but her expression was 
immobile and tranquil. 

It is stated that the electro-muscular contractility is not affected, but 
reflex excitability seems to be diminished or lost entirely, so that 
sometimes it is almost impossible to determine whether the patient is 
alive or dead. The so-called trance states are examples of this kind, and 
catalepsy has undoubtedly led to burial alive in many instances. 

The ordinary attacks usually subside in a few hours, the rigidity grow- 
ing lc<s marked, and consciousness gradually returning. The attacks, as a 
rule, follow each other in a series, and then comes an interval of normal 
health. In this mode of appearance and behavior, the disease has been 
likened by Eulenburg to neuralgia. " Strictly speaking, it is rather a 
cycle of attacks quickly following one another;" and there are remissions 
characterized by temporary return of consciousness, and then a fresh re- 
lapse, which evidently follows some internal irritation. In rare cases 
then- is a sudden return of consciousness and an ability to perform volun- 
tary acts. The urine and feces are rarely passed in an involuntary 
manner. 

Unless the disease be due to malaria, it becomes chronic, and continues 
for years. If it is due to malarial poisoning, it usually assumes a regular 
periodic character, and is amenable to treatment. 

Causes Like many other neuroses, such as hysteria, epilepsy, and 

tin)-'' of this class, mental excitement plays no mean part in the etiology 
of catalepsy. Fright, and other forms of emotional excitement enter into 
it- causation. Injury and malaria may also be mentioned; while mastur- 
bation, venerv. and intestinal worms are spoken of by writers generally. 
JaCCOud considers it to he a re8ull Or accompaniment of certain forms of 

melancholia (Melancolia attonita), and ecstasy. 

It appears as if it were more common in early life, and children are 

therefore nearly always the \ieiims. Anaemic girls, or hoys especially 
who Btudy too constantly, are affected more often than those of adult life. 
Nearly nil writer- agree that the female is more subject to the disease 
than the male, mid probably fcoe delicate organization of the sexual appa- 
ratus has much lit do with this. 1 Ieredila rv influences seem to play a 

part in the etiology only bo \':w as the general neurotic tendency is con- 
cerned. Families in which there are epilepsy, neuralgia, and insanity 






CATALEPSY. 391 

sometime- include cataleptic members. I have never heard, and I can 
find no record, of transmitted catalepsy. 

Morbid Anatomy and Pathology — Besides the examinations 
made by Calmeil ami other older writers, which, by the way, throw very 
little light upon the question of pathology, Schwartz made one autopsy, 
and Lasegue two, but nothing was found by the latter observer. 

Schwartz' mention- the case of a boy "who, after an injury, had at first 
attacks resembling chorea, later cataleptico-tetanic attacks, and after two 
years died from anaemia and marasmus. There was found in this case, 
besides a serous effusion in the arachnoid, a softening of the corpus .stria- 
tum and optic thalamus, especially on the left Bide ; along the posterior 
surface of the spinal cord, from the cervical to the lumbar enlargement. 
was a brownish-red, jelly-like mass, arranged in group-, covering the dura 
mater. The spinal cord seemed healthy. (There was no microscopic 
examination.)" 

Catalepsy, which is associated with many other interesting perversions 
of consciousness such as somnambulism, stigmatization, etc., has received a 
great deal of attention, not only from the laity, but from scientific men of all 
ages. It is not my purpose to enter extensively into the consideration of 
these various curious states. The lighter forms, such as the "catalepsie 
-ere'' of Lasegue. 2 have been induced, by mesmerists and others, by 
passing the hand over the lace or body, or by closing the eyelids. The 
same condition may be induced by looking fixedly at some bright object 
held close to the face. 

A remarkable experiment of a popular nature, which I have repeatedly 
performed myself, is a curious instance of the susceptibility of certain 
animals to influences of this kind. If a lobster is placed head downwards, 
and gentle scratching of the back be made, it will become perfectly quiet, 
no matter how pugnacious it has been before, and will remain in this 
position for some time. 

The general opinion in regard to the pathology of the affection is that the 
peculiar muscular condition is due to an increased muscular tone, which 
probably depends upon impaired voluntary control, so that the mi - 
respond to trivial irritation reflected upon the spinal ganglion cells. 

Volition is checked just as it is in hysteria; and when we consider the 
theory of " expectant attention," advanced by Carpenter, the genesis of 
some form- of catalepsy is easily explained. These are the varieties in 
which the individual become- cataleptic when influenced by another. 

Diagnosis. — The waxy flexibility, which is pathognomonic, is not a 
feature of any other disease, and this, taken in connection with the loss of 
consciousness and anaesthesia, makes the diagnosis a matter of certainty. 
The only point which should interesl us i- the possibility of simulation. 
Numerous instances of so-called stigmatization come under this head. 
There i< abundant opportunity for detection, however; and electricity, 

1 Quoted by Eulenburg in Ziemssen'a encyclopaedia, vol. \iv., translation. 

Aivhiv. de Med.. L865. 



392 CEREBROSPINAL DISEASES. 

mental influence, and strong cutaneous revulsives are recommended should 
we suspect malingering. 

Prognosis When the cause is emotional, or when there is a mala- 
rial influence, the individual's chances arc remarkably good. It is only 
when the disease appears in a subject of very marked nervous tempera- 
ment that there is any reason to give a bad prognosis, and such cases are 
chronic. A fatal termination is a very remote possibility. 

Treatment Electricity in its induced form seems to be indicated for 

the abortion or relief of the paroxysm, and amyl nitrite may be recom- 
mended for the same purpose. Should there be malarial influences, qui- 
nine, arsenic, or iron is of course in order. Curare, bleeding, and many 
other forms of treatment have been useless. In the transitory affection 
(catalepsie ]jassagere) cold water douches, or diffusible stimulants, are 
resorted to. 



CIIUREA. 393 



CHAPTEE XIV. 

CEREBROSPINAL DISEASES (Continued). 
CHOREA. 

Synonyms. — St. Vitus's dance; St. John's dance; Paralysis vacil- 
lans; Tarantismus; Choree etc. 

Definition. — Chorea is a disease characterized by involuntary and 
disorderly movements of the muscles, is unattended by loss of conscious- 
ness and cutaneous sensibility, and is generally connected with paresis of 
certain groups of muscles, or those of one side of the body. 

As early as the fifteenth century, a species of religious delusion appeared 
in Southern and Middle Europe, in an epidemic form, and was connected 
with certain saltatory and muscular phenomena, which gained lor it the 
name of St. Yitus's dance. 

This is described by various writers as a condition of religious excite- 
ment characterized by gesticulations, contortions of the body, and leaping, 
while the patient generally screamed or howled like an animal. This 
peculiar state was supposed by the older writers to be demoniac possession, 
and many victims were made to undergo the ordeal, or were put to death 
by the sword, or burnt at the stake. Under the influence of their con- 
dition they sought the shrine of St. Vitus, which was situated in a small 
chapel near Zabern. Here they were cured by the priests, who sang 
masses and removed the disorder. 1 

Various epidemics appeared subsequently, hut the disease gradually 
became divested of its noisy character. In Italy a dancing disease, sup- 
I to be due to the bite of a spider, and which received the name i^' 
tarantism, made its appearance in the early part of the sixteenth century, 
while, at the same time, a peculiar outbreak occurred at Amsterdam, where 
seventy children of the Orphan Asylum became possessed. They climbed 
the walls, swallowed needles, hairs, pieces of glass, and other indigestible 
Bubstances, and "distorted their features and limbs in a fearful manner." 1 

At other place- the same thing occurred, and until the end of the seven- 
teenth century, when there was some decrease in superstition, instances of 
this kind of chronic disorder were common. 

Symptoms. — The beginning of a simple case of chorea may be the 
following: The patient, a boy of ten years, who attends BChool, becomes 
irritable, loses appetite, and does not care to go out and play n\ ith his fel 
lie becomes pale and thin, and -it- by himself. En a little while some move- 



1 Reynolds's System of Medicine, vol. ii 

2 Scheie dc Vere's "Modern Magic," p. 



• >>l 



304 CEREBRO-SPINAL DISEASES. 

incut of the hand or fingers, some twitching of the face, or dragging of 
one toot when he walks, attracts the attention of parent or teacher. He 
may be punished, with the idea that such movements are the result of bad 
habits or viciousness, but it does no good, but probably increases the 
trouble. These jactitations cease at night, when he rests uneasily, and is 
disturbed by bad dreams. This is the condition in which we find the patient. 
What is the course of the disease? If he is neglected, it will not be long 
before the convulsive movements become general. The feet may drag 
along a- if paralyzed, and such is the case. He will be unable to button 
hi- clothing, or attend to his little wants, and may need the careful and 
constant attention of his friends. The vocal cords may be affected, and 
there is as a result a certain aphonia, so that phonation is husky and sub- 
dued. Incoordination of the lips and tongue gives rise to difficulties in 
articulation, which are quite distressing, the words being "snapped" and 
cut short. 

The symptoms are worthy of separate consideration, and we will proceed 
to discuss them in their order of importance. 

1. Motility? — The spasms, as I have said, are clonic, and are more 
often unilateral than bilateral. The right hand is usually affected first, 
then the leg of the same side may follow, and finally the other side may 
be implicated, so that the movements are general. The arm is usually 
affected before the face, though in several of my personal cases the first 
symptom noticed was a slight twitching about the mouth, and an awkward 
tendency manifested by the child to open the mouth and draw its breath 
while speaking. In another, the little boy first attracted the notice of 
his mother by movements of the ahe of the nose. 

I do not think that the movements in chorea are always increased by 
the effort of the will to stop them, as is the case in sclerosis, in which disease 
the tremors are exaggerated by any ♦voluntary attempt of the individual 
at control; and I have often been led to suppose that chorea might be 
divided into two varieties, viz., one in which the movements are increased 

with the exercise of the will, the other when they are most violent in a state 



1 In .in excellent report of so cases of chorea,* made l>\ Dr. (i. S. Gerhard, 
of the Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases, the 

following points were observed: — 

Movement. — In 27 cases, general. 

11 " " but marked on right side 

in << « " « left 

82 " unilateral, 20 on right, L2 on Left side. 

In ;i certain number of these cases the movements shifted to the other side. 
Paralysis. Partial paralysis noted in 1 7 cases. Loss of power in 10 instances 
confined to righl Bide, in 7 to Left. 

[ffe. -UnderlO years, 28 cases, 9 m., 10 fern. 
From i" to-flO " 52 " 18 " 84 " 

_ — — 

Total, 80 " 27 " 88 ' 

Cure in 56 cases, i 1 1 1 j >i« > \ emenl or "resull unknown" in 24 case's. 



:: \ 1 1 1 • i . Joiirn. Medical Sciences. 



CHOREA. 395 

of rest. 1 The movemeDts of the hands are characteristic, I think. There 
is a prehensile movement of the fingers and a robbing of the ball of t ho 

thumb and ends of the fingers. There is Bwinging of the arm. and a 
shrugging of the shoulder, as if the patient had on large or uncomfortable 
underclothing. 

There is a trivial point which may perhaps be of interest, and I only 

mention it because it is unique. I allude to the habit which these little 
patient- have of rubbing the scam of the trowsers Ion by the hand which 
is affected, for these movements often go on most actively when the arm 
hangs by the side, and when the attention is not directed to it. In other 
diseases just such "little straws" will once in a while give a serviceable 
hint: for instance, in commencing paresis of any kind of the lower 
limbs. If Ave examine the tip of the shoe, we will find the sole to lie 
worn down on one side of the body. In locomotor ataxia we will find a 
reduction of the heel. When these little patients are worried or embar- 
rassed, the movements are greatly increased, and this is one of the strong 
features of diseases of this kind. I have at present a patient at the I!. -- 
pita! A\ho is almost quiet when in the presence of people he has been 
ciated with for some time, but every new face seems to excite him to such 
a degree as immediately to give rise to the most violent movement^. 

The loss of power, which is very often a phenomenon of chorea, is nearly 
always one-sided, and when it exists to a marked degree, may greatly 
affect the patient's walk, so that he drags his foot in a helpless manner. 
Handfield Jones thinks that the want of power is a constant feature of the 
disease. Such paresis i< extremely variable, however, in its extent. 
Muscular exertion is distressing, and he may not have the power to per- 
form some of the least fatiguing actions of daily life without great prostra- 
tion. 

The muscles that are most paralyzed are always those which have been 
the seat of the most violent spasm. 

Sensation There may be pain in the wrists if the spasms are severe, 

or the skin may be anaesthetic ; such los< of sensation being confined to 
the whole paralyzed Bide, or to a single limb. 

Mental Condition Irritability of temper and emotional excitement 

are present from the beginning, and the child i< restless, sleep- badly, and 
is tortured by bad dreams. Study or mental application is an impossibility, 
and spells of crying are quite familiar evidence of the disease, especially 
in the earl}- stages. Chorea may exist in a very Bevere form when there 
is a grave exciting canst' ; and the convulsive movements may be so vio- 
lent as to render it necessary to bind or hold tin- patient in bed. At the 
request of Dr. J. P. P. White, of New York. I saw with him a c: - 
this kind. 

The little girl, who was about ten yean of age. had arrived in N<w" 

York after a sea-voyage, during which the symptoms began. We found 
her agitated by violent Bpasms of all four extremities, which had lasted 

1 In ;i recent conversation with my friend Dr. S. ^ sir Mitchell, he remarked 
that he had often recognized the necessit> for such a division. 



396 CEREBRO-SPINAL DISEASES. 

for several days, and it required constant watching to keep her from throw- 
ing herself out of bed. They ceased partially during sleep, but this needed 
repose was denied her to a great extent. Her skin was hot, and her 
pulse hounding and full. She was perfectly conscious, but complained of 
pain in the wrists. I inferred, from the general character of the convul- 
sion-, their constancy and violence, and from other symptoms, that, there 
was some form of eccentric irritation; and an anthelmintic administered 
by Dr. White brought away a tapeworm several yards long. The move- 
ments disappeared in a very short time. 

The urine has been found by Walshe and Bence Jones to be of much 
higher specific gravity than in health, and to contain an excess of urea. 
It may vary from 1030 to 1040, and is loaded with the oxalates and 
lithates. 

Another form has been described which is characterized by paroxysms, 
during which the patient may perforin the strangest antics. Her condition 
before and after the attack is one of quietude, but without warning she be- 
comes agitated by spasms, rolls on the floor, jumps in the air, or rushes 
about the room. "Wood reports a case of this kind in which the patient, 
a \ oung married woman who had been slightly ill for some time, developed 
this paroxysmal variety. " The paroxysms themselves were not always 
of the same kind. At one time she would be violently and rapidly hurled 
from side to side in the chair in which she might happen to be sitting, or 
else suddenly gaining her feet she would go on jumping or stamping for a 
while 1 ; or, she would rush around and around the room, and raj) witlt her 
hands each article of furniture which lay in her course ; or she would 
spring aloft many times in succession and strike the ceiling with the palm 
of her hand, so that it became necessary to remove some nails and hooks 
which had done her an injury ; or she would dance upon one leg with the 
fool of the other leg in her hand." 

A professional friend has recently informed me of a case of this kind 
which came to his knowledge, in which the woman was affected very much 
in the same way as the patient of Mr. Wood, and that on one occasion she 
Created great commotion by attempting to climb one of the stanchions in 
the cabin of a steamboat. 

These cases are so rare, however, that they only deserve to be men- 
tioned en /xissiiiit as examples of the irregularity of the disease, and are 
somewhat like the original dances of St. Vitus and St. John. 

The following case illustrates a very curious phenomenon of motility 
which I lately noticed : — 

Thr patient, :> b<>y of ten years, was broughl t<> me by his father for 
treatment, after having been seen by many practitioners, who did not agree 
in regard to his condition. I saw that his movements were choreic. Ques- 
tioning revealed the fact that. he hud never been a strong child, but had 
always been disposed to neryeus troubles ; even the exanthematous fevers, 
which, like other children, he had had, were generally connected with 
Btupor, and other evidence of susceptibility of the nervous substance to 
blood-poison. He never had any rheumatic or cardiac affections, and I 
could hear nothing to indicate valvular trouble. The heart-sounds were 






CHOREA. 391 

sharp and quick, however. Four years ago he began to decline, became 
weak and anaemic, was irritable, moody, and bad-tempered. His appetite 
was capricious, and he preferred sweets to other food. In the summer of 
1872 the movements in the hands and arms began, and soon became gene- 
ral. His rest was uncomfortable, and he started up in his sh ep and cried 
out. When I saw him four months ago he was a pitiable object. His 
movements were general. lie was unable to hold anything, and was 
powerless to perform any voluntary actions except those of a gross kind. 
He could not unbutton his clothing or put on his cap; his mother even 
had difficulty in making him walk. 

Variety of Movement Head was violently agitated, there being eon- 
tractions of the sterno-eleido-niastoideiis. I Ie " sucked in his cheeks," and 
pursed up his mouth, smacking the lips. Other facial contortions were 
violent. He winked spasmodically, and there was constant motion of the 

eyeballs. 

The arms were in constant motion, hut the right was not affected so 
much as the left. The right arm and hand were slightly paretic, and he 
was able to force the column of fluid in the fluid dynamometer up to L6 , 
which is equal to 15 lbs. pressure to the square inch. The left forced it 
up to 18°. 

The legs. The right leg was also slightly paretic. The toe of the shoe 
was worn down to some degree, although the walk was not noticeably 
atl'eeted. 

There was an uneasy rolling of the pelvis when he sat down, and the 
legs were not entirely under his control. There was pain in the wrists 
and ankles. Under proper management of his diet he gradually improved, 
and at the last visit was nearly well. I noticed then for the first time the 
following peculiar state of affairs. When sitting in front of me, I told him 
to raise his hands, one after the other. The right hand he raised promptly, 
but the left he could not, unless he took hold of the wrist with the other 
hand, and lifted it. This condition struck me as remarkable, especially 
as he had to repeat the process of aiding with the right hand. 

The left hand and forearm might "be paretic. There was no loss of 
electro-muscular contractility, however, but, if anything, it was increased. 
The muscular power, tested by the dynamometer, was found to be even 
better than in the other hand. There was no atrophy. With these facts 
in view, it seemed improbable that this should be the cause. 

It was found that when the other hand was held down, the boy was 
able to lift his left hand unassisted, and even to raise a dumb-bell weighing 

10 lbs., but as soon as the other hand was released he was unable /<> r, - 
peat it. 

To determine whether this was the result of any bad habit, I ascertained 
from the father that his son had never used one hand to lift the other till 
a few weeks ago. 

In adult life forms of chorea are met with which in nearly every respect 
resemble those of infancy. Sometimes pregnancy is the cause, and in 

other cases prolonged emotional excitement, and more especially grief, are 

in some way connected with the development of the disease. 

My case-book contains the records >>f several of these examples, and 

their form is usually of thai hind which is known as hemichorea. and \<r\ 

often seems to be dependent upon some true organic Lesion. In this term 
the exercise of the will to stop the movements is generally provocative of 



398 CEREBRO-SriNAL DISEASES. 

a decided increase in their violence. The patient is unable to carry 
food to his mouth, to manage his clothing, or to perform any little acts 
of necessity, lie tears to make any attempts in the presence of other 
people, and this is especially the ease before strangers. I have already 
alluded to one instance of this kind. In another patient the mere sugges- 
tion of meeting a new physician was sufficient to aggravate her convulsive 
movements. 

The chorea occurring during pregnancy generally disappears before 
parturition, and though Jaccoud considers that it may lead to miscarriage, 
and though he has found the mortality greater than in any other form, I am 
not disposed to agree with him as to the serious character of the disorder. 

An instructive case of this disease is subjoined : — 

Mary K., sat. 24, entered the Epileptic and Paralytic Hospital July 
10th, 1*77. She is of nervous temperament, and gives a family history 
of nervous disease. Her sister has epilepsy, and a brother has infantile 
paralysis. Up to the 5th day of June, 1877, she was perfectly well. 
While in bed she was awakened by a storm at about 3 A. M., and was 
greatly frightened by the loud claps of thunder and the vivid lightning. 
She arose and tell to the floor, where she lay for some time, crying, but 
found no difficulty in arising, there not being paralysis. The next day 
she felt "a cramp" in the left side, and the leg and arm were spasmodi- 
cally contracted, and afterwards began to twitch. There is no pro- 
found loss of power whatever, but some slight paresis of the left side, and 
a derided hyperesthesia of this part of the body. The left upper and 
lower extremities were convulsed by choreiform movements, the hand 
being more agitated than the leg. The strength of grip is decidedly 
weakened, and she is only able to force the fluid index in the dynamo- 
meter up to 8°, while with the other hand she raised it to 14°. There 
i- some dragging of the foot when she walks. She does not sleep, but 
requires chloral and other hypnotics. She is in her seventh month of 
pregnancy, and it was decided not best to try any very active treatment. 
Arsenic was given, however, in the form of five-minim doses of Fowler's 
solution, and she became more quiet under its use. At no time has she 
shown any indication of impending abortion, and though feeble and ame- 
nde. -h<- is able to go about and enjoy herself in a limited way. 

Aug. 25. Fowler's solution increased, so that she takes tr^x. t. i- d. 
Moi ementa somewhat lighter. 

Srj,t. 20. Gave birth to a healthy boy after a short Labor. 

<ht. K». Cured. Discharged. There were no special temperature 
variations at any time. 

A case of interest is that of — 

I. n;i ('.. at. I 1 : ( .ernianv ; married. Her mother had chorea at the 

same age. About four years ago, withoul any appreciable cause, convul- 
sive movements of the whole body began. These were not general at first, 

and were Limited only to the upper extremities. The movements are 

bilateral, and agitate the hantts more than any other part. The facial 

muscles are -lightly a llectedt and there is a jerking upwards of the corners 

of the mouth, more especially on the right side. The movements are neither 
ivated nor controlled by the will, but cease during sleep. Hercutane- 

QBibility ifl in HO Way affected, and her sight and hearing are both 






CHOREA. 399 

good. She has ;i Btrange habit of clutching her dress in front, probably 
to steady her bands, and when spoken to she seems greatly disconcerted 

and moves more than ever. 

June '2't. Fl. ext. conii, n^xl, t. i. d. ordered by visiting physician. 

26tk. No marked toxic effects of the drug apparent, except dilatation 
of the pupils; and the patient says that there is a "complete lightness of 
the body," and that "she could fly." Some improvement in movements. 

With a strong voluntary effort the movement- are stopped tor a time. 

July 10. Great improvement; patient can hold her arms quite steadily ; 
medicine stopped (case-book does not say why). Discharged at her own 
request Dec. 15, 1875. 

She re-entered Dec. 2'2, 1875., I found the patient in probably 
the same state in which she first came into the hospital. She i< a 
spare, tall woman, very restless and emotional. She cannot express her- 
self at all, for when she attempts to speak the tongue refuses to do its part 
in articulation, and the result is the utterance of ill-arranged sounds, 
which are not properly formed into words. She .-mack- her lips, and 
"clicks" her tongue against the roof of the mouth, and the sounds which 
eome forth are tremulous and agitated, and just such as one would expect 
to hear from a person who was agitated by some great fear. The con- 
tortions of the arms are very violent and irregular, ami almost defy de- 
scription. The body seems to twist upon the pelvis ; the arms are thrown 
backwards and forwards, and the hands and fingers are constantly work- 
ing. She seems to have no volitional control over her limbs, ami has very 
little muscular force. She walks without any apparent embarrassment, 
but when seated the movements in the lower extremities are more active 
than when she stands up. She was somewhat analgesic, as was demon- 
strated by pinching. Treatment with strychnine considerably moderates 
the violence of the spasmodic movements. 

Chorea may often present a periodic character, especially if malaria 
enters into its causation. The tendency to relapse is quite a striking 
feature, and, in many cases which I have seen, it appeared either during 
the early fall or spring, and reappeared the following season. It may be 
accompanied by other nervous troubles, or exist in an uncomplicated form 
as a result of debility arising from repeated nervous exhaustion or fresh 
eccentric causes. In one case I found it to appear as soon a- cold weather 
came, and at tin? same time an extensive eczema upon the calves of the legs 
and scalp was developed. This disappeared, together with the movements, 
under the use of arsenic and oil. but both reappeared the following winter. 
Dr. E. Frankel has reported a similar case, and I have no doubt there are 
others who have had a like experience. The disease usually wears itself 
out in a short time, the tendency to relapse rarely lasting after puberty ; and 
if a cure can be effected, the maintenance of a high standard of general 
health and certain precautions a- to overwork or -tudy prevent a return. 

Causes — Various writer- agree that the di- aimed to the 

period between the third and fourteenth year.-, and this has been m\ i \- 
perience. I do not know of a case under three years, but Hammond has 
Been the disease in a child of eighteen months. Watson limits the time 

at which chorea may appear to the period between the lir-t an ! -< coiul 



400 CEREBRO-SPINAL DISEASES. 

dentitions; and Hillier, of Great Ormond Street Children's Hospital, lias 
given a table, which is referred to by Radcliffe. He found that of 422 
cases at the above institution, 104 were between the ages of ten and 
twelve. Girls seem to be more often affected than boys, for what reason I 
cannot say. except that it may be the more delicate organization of the 
former, and the preparative changes going on before menstruation. 

Niemeyer believes the malady to be very rare before the sixth year and 
after the fifteenth. When the disease appears after puberty, it generally 
in eccentric form, or it may be due to central organic changes, or fol- 
low hemiplegia. This latter form, denominated by Mitchell post-paralytic 
chorea, has already been described. In chorea there is a general derange- 
ment of the digestive organs and loss of appetite ; constipation and palpi- 
tation are quite common alterations of function met with in these cases. 
In the anaemic patients, and they are generally all so, there is often an 
aortic murmur, and the skin is pale and cool. 

The existence of cardiac disease or the previous history of rheumatism 
is considered by many authors to have much to do with the causation of 
the disease. Romberg, Hughes, and West, besides many others, have so 
decided ; and when we consider the pathology of the disease, it will ap- 
pear to us very reasonable. Of 104 cases of chorea at Guy's Hospital, but 
15 of the number were free from any indication of cardiac or rheumatic 
difficulties. 

The disease often follows scarlatina or other zymotic febricuhe, or takes 
it- origin from an attack of acute rheumatism. It may result, and gene- 
rally does, from some directly exciting cause, such as over-study, bad air, 
or food, worms, or sudden fright. My recent investigations in regard to 
the occurrence of the disease among school children revealed the astound- 
ing fact that over twenty per cent, of young school children of the public 
school- of New York were affected wiih choretic affections of greater or 
less gravity. West 1 expresses it as his opinion that over-study is a com- 
mon cause, and my investigations are sufficient to prove this. 

Many cases are Bupposed to result from association of unaffected children 
with those who are the subjects of chorea. Niemeyer alludes to the prev- 
alence of this " mimetic form" among boarding-school pupils. This view 
has been very popular with the laity, and I am convinced has some im- 
portance, still. I cannot but think that the influence of example has been 
grossly exaggerated. 

.Miliaria .-eems to play a decided part in the etiology of the disease. 
This was pointed out, by Kinniciill, who reported some interesting cases 

in which the movements were aggravated at certain hours on alternate 
days, and were characterized by something like periodicity. 

1 Am. Psychological Journal, Feb. 1876. A Dumber of papers containing 
questions were Benl n> the publig Bchool teachers of this city. In most instances 
tin answers were intelligent and satisfactory. The cases alluded to above varied 
from movement of the handa and twitching of the facial muscles to general move- 
on ut - which at tractei I i he attention <>l' \ eit<»r->. 



choke a. 401 

Morbid Anatomy and Pathology. — But few cases of fatal chorea 
have been reported. Twenty-two of these are brought forward by Dr. 
Dickinson, whose excellent article upon the pathology of chorea deserves 
the attention of" every student of neurology. One case has been reported 
by Ellischer, 1 which is instructive, as it exhibits changes in the nerve- 
trunks; and Ogle, 2 Kirkes, 8 Hughes, 4 and Romberg 5 have made autopsies 
in other cases. In Dickinson's cases the heart was found to be healthy in 
live ; in the remaining seventeen the following lesions were observed: — 

Recent vegetations on mitral valves only, . . . seven. 

" •• " •• with old thickening, one. 

Recent vegetations on mitral and aortic valves, . . one. 

Recent vegetations on mitral and aortic valves, with peri- 
cardial adhesions, ...... two. 

Recent vegetations on mitral and tricuspid valves, . one. 

Recent vegetations on mitral and tricuspid valves, with 

pericardia] adhesions, ...... one. 

Recent vegetations on mitral and aortic valves, with 

recent pericarditis, ...... two. 

Recent vegetations on mitral valves with old pericardial 

adhesion.-. ........ one. 

Of the patients affected with recent endocarditis, 6 originated from 
rheumatism, 2 from mental causes, 3 from uterine, 1 from rheumatic and 
uterine, 2 from mental and uterine, and 3 from unknown causes; thus 
showing the connection between the rheumatic origin and the cardiac 
changes. 

The brain and cord were affected in 11 cases, there being congestion, 
softening, and appearances similar to those noted by the other observers I 
have mentioned. 

In one of his cases (No. V.) he made xevy thorough microscopical 
examinations, and I present his account of the appearances noted: •• Sub- 
sequently sections from almost every region of the brain were examined 
microscopically. They were in most instances natural, the nerve-cells 
invariably so, save some injection of the vessels, not enough to be decidedly 
morbid; though the veins were much distended, in particular about the 
dentate bodies of the cerebellum, the vessels and their canals were nor- 
mal. There was no extravasation, effusion, or erosion. Two situations. 
however, were remarkable exceptions to these statements. In the deeper 
white matter of one of the cerebral convolutions were many conspicuous 
spot-, which consisted of accumulations of crystals of hsematine mingled 
with indefinite debris^ probablj of nervous origin, swelling the canal- 
around arteries which still remained distended with blood. 



1 Archiv flu- Path. Anat., etc.. t. l\i. 

1 Brit, and For. Med.-Chir. Review, 1868; Med. Times and Gaz., 1866. 
3 London Med. Gazette, 1850; Med. Times and Gaz., 18 
1 Guy'a Hospital Reports, vol. i\\. ;■ 3 Op. cit. 

26 



402 CEREBROSPINAL DISEASES. 

"The other region referred to as the seat of significant change is thai 
of the corpora striata. These bodies were more minutely injected than 
the resl of the brain. The capillaries, as well as the larger vessels of both 
classes, being packed with blood-corpuscles and numerous spots, striking 

object- under the microscope, were closely set in their substance. These 
consisted each of an artery in section, empty, crumpled and collapsed, and 
surrounded by a mass of globular debris, which had been formed at the 
expense of the surrounding tissue. They had evidently been produced by 
;i solution or destruction of tissue around the vessel consequent upon effu- 
sion from it. the result of injection which had now ceased to exist. In 
time these mixed effects of extravasation and disintegration would have 
disappeared and left mere vacuities. 

••The spinal cord displayed loaded vessels and eroded fissures, such as 
were Been in every other instance examined. In addition to these com- 
mon changes, the gray matter had undergone extensive transformation of 
the kind to which the term sclerosis has been given. This was slight in 
the cervical region — extreme throughout the dorsal — absent from the lum- 
bar. The change was confined to the gray matter, which it affected on 
tin -ante side of the cord nearly symmetrically. In the dorsal region it 
involved at least a third of the gray matter as seen in section ; the 
affected portions on each side being adjacent to the attachment of the 
transverse commissure, and at the roof of each posterior horn. In the 
cervical region, though the change was less extensive, its position was the 
same. The altered gray substance had been converted into a wool-like 
entanglement of curving areolar fibres, among which nerve-fibres could be 
sometimes traced, especially near the edges, but from which all other 
nerve-elements had disappeared, Leaving a mere confusion of connective 
tissue. The nuclei proper to the healthy structure were present, but had 
undergone no increase, nor was there any other evidence of fibroid or con- 
nective new growth. The change seemed to consist essentially of a 
destruction and removal of tin- nervous elements, their fibroid skeleton 
only renminbi 

A fatal case of chorea was reported by Dr. Jas. 11. Hutchinson. 1 The 

heart was found affected, the aortic valves incompetent, the leaflets being 
••swollen and softened." and the aorta was atheromatous above (he sinus 

of Valsalva. 

KHischer,'- who made an autopsy, found that the \ ascular changes in the 
brain were marked, the walls of the vessels being changed, and the surface 
Covered by dark granules. In certain places (he calibre of the vessels 
WM narrowed, and there was an accumulation of blood-corpuscles, ami 
consequent effusion of the watery parts of the blood. Some of the \essels 

contained coagula. The connective tissue about these vessels was thick- 
ened and increased in size, and contained yellow pigment and granulated 
nuclei. The large ganglionic Cells in the brain were filled with pigment, 
mi I the cell contents much whanged. Sections of motor nerves exhibited 

i phila. Med. Times, August ... I - 2 Op. cit. 



CHOREA. 



403 



red patches, and destruction of nerve-fibres. These changes -Low. then, 
great vascular alteration, and degeneration of normal nerve-tissue. 

In regard to the pathology there is much dispute some observers con- 
sidering it to be but a functional condition, while others are well satisfied 

as to its organic nature. 

The original observations of Kirkes first demonstrated the relation be- 
tween chorea and rheumatism. Ogle contends that this relationship (or 
at least the evidences of rheumatismal causation in the brain, such as em- 
boli) is only demonstrated by fatal cases. He considers the exec-- of 
fibrin in the blood to be only the result of the same influence that pro- 
duces the chorea, and that the blood state, instead of being ;i cause, may 
be a consequence of chorea, the result of tissue metamorphosis due to 
excessive muscular action. 

lie raises a question as to the disappearance of the movements, and 
considers this condition of affairs incompatible with organic lesions. This 
objection, however, seems to lack force when we remember that in aggra- 
vated cases the movements do not stop during sleep. Another fact is to 
be thought of, and this is the tendency to relapse which the simplest cases 
present. 

The embolic theory has been reported by nearly every investigator, and 
its strongest supporters are Broadbent, Hughlings Jackson, ami Bastian. 
The original investigations of Kirkes served as a basis for this new theory. 
He found that particles of fibrine were washed into the cerebral vessels. 
Hughlings Jackson located the place of final deposit in the gray matter of 
the convolutions in the neighborhood which are supplied by the middle 
cerebral artery. Jackson very cogently considers the significance of its 
one-sided character as compared with hemiplegia from embolism, and has 
since brought up the question of involvement of the muscles more con- 
cerned in special voluntary acts, which are likewise conspicuously affected 
in hemiplegia and epilepsy. 

Against this theory, some writers have raised the question in regard to 
the existence of the hemichorea on the same side of the body as that of 
the brain where the lesion is found, and contend that there must be 
crossed action. 

Dupuy and Brown-Se piard have made experiments which prove that 
such a. condition of affairs may exist, and I have myself done the same 
thing. Since my experiments. 1 have heard of a case, related by Dr. 
Walter Hay. of Chicago, in which post-mortem examination revealed a 
cerebral hemorrhage on the side of the hemiplegia. 

In one of these experiments made by Dr. F. II. Rankin and myself upon 
a monkey, electrical irritation (galvanic) of the white matter just beneath 
the cortex of the left ascending parietal convolution produced convulsions 
in both extremities of the same side. 

Broadbenl localizes the lesions entirely within the corpus striatum. lie 
also calls attention to the existence of peripheral irritation. >hoek, and 
various causes which may produce a depraved functional condition. 

Bastian adopts die theory thai the emboli consist of masses ofagglome- 



404 CEREBRO-SPINAL DISEASES. 

rated white corpuscles, and that the location of the lesion is in the corpus 
striatum. 

Dickinson is disposed to regard the chorea as the result of rheumatism 
rather than of endocarditis, and considers the central condition one of 
hyperemia of the nervous centres, "not due to any mechanical mischance, 
luit produced by Causes mainly of two kinds: one a morbid, probably a 
humeral, influence which may affect the nervous centres as it affects other 
organs and tissues ; the other, irritation in some mode, usually mental, 
hut sometimes what is called reflex, which especially belongs to and dis- 
turbs the nervous system, and affects persons differently according to the 
inherent mobility of their nature." 

In regard to localization he agrees in the main with the other observers. 
•• The spots of perivascular change are widely scattered throughout that 
large region which lies inferiorly to the cerebral convolutions between the 
corpora striata and the lower end of the cord; the district of the motor 
ami sensory as distinguished from the mental functions." 

It seems, then, that the quality of the lesion is only disputed. I am 
Strongly inclined to accept the embolic theory, not only because the pare- 
sis of the limb may precede any muscular movements, but because lesions 
in or about the corpora striata, which produce hemiplegia, may also give 
rise to choreic movements. 

Diagnosis. — The movements of chorea must be differentiated from 
those of sclerosis and paralysis agitans. This will not be a difficult task, 
aa fie peculiarity of the choreic movement is the jerk, while the tremor of 
the other affection is rhythmical and usually fine, and varies under certain 
circumstances. The rapid recovery should also be an element in the 
diagnosis. 

That chorea may result in some secondary disease, such as softening or 
meningitis, is well settled ; and in these cases it will be necessary to take 
into account the character of all the new symptoms, and the history of the 
old ones. 

The exceptional forms of the disease may be mistaken for hysterical 
troubles, and then the diagnosis will be difficult. If must be borne in 
mind, however, that this mistake can be made only in adult cases. The 
paralysis of chorea may be differentiated from true cerebral or spinal para- 

ii\ its gradual development, and by the age of the individual, as these 
two form- are quite rare in infancy. Choreic movements usually stop at 
night, and the exceptions to the rule of quiescence during sleep include 
those in which the patients have "dreams of movement," such as were 
alluded to by Marshal] Hall. 

Prognosis.- •( 'horca is an affection which may very often disappear, 
without ;ni\ treatment whatever, in from si\ weeks to four months; bu1 
there are verj likely to be relapses. If properly treated, the movements 
should disappear in from -i\ weeks to two months, or even in a shorter 
time. If the disease appeffrs after puberty, the prognosis is unfavorable, 
and nil we can do in some cases is to moderate its violence. There is 
a tendency to recovery in other cases, among them those of pregnancy. 






( itorea. 405 

Death is a very unusual termination, and it rarely occurs as a result of 
the disease itself, but rather of some cardiac complication. 

Treatment Internal remedies: Strychnia; arsenic; iron in it- 
various forms (bromide, carbonate, etc.) ; phosphorus and cod-liver oil. 
External remedies: Cold to spine — ice, ether spray, and cold douche; 
Russian or Turkish baths; and salt baths. Rest, diet, and fresh air. 
(VV. 7, 9, 10, 11, 13, 14, 24, 28, 2!), 32, 42, 43, 51, 58, 72.) 

Some of these maybe combined with good effect. The plan of treat- 
ment I generally employ is the following: Should the child be ••inn 
down," as is generally the case, I begin with some preparation ot* iron, 
and administer at the same time cod-liver oil. As regards special treat- 
ment, I find strychnine serviceable, carried up to the point where stiffness 
of the sural muscles is arrived at. Next to ibis stands arsenic It 
must be given in large doses; but when we find that digestive troubles 
are produced very quickly by this drug, strychnia may be substituted. 
Cold to the spine cannot be overestimated as a plan of treatment. We 
may either use the ether spray, which was first suggested for use in 
this disease by Subetski, of Warsaw, in 1866, or apply ice-bags every day, 
allowing them to stay on about ten minutes. Perroud, who has used the 
ether spray, makes applications from four to eight minutes in duration 
every day. Of thirty-live east's I have treated in this way (I mean with 
the ether spray), from fifteen to twenty applications produced permanent 
benefit ; and here I would say that the spray should be directed chiefly to 
the upper part of the cord, over the upper cervical vertebra?. Eserine has 
been lately recommended, and Bouchut has given the results of 437 eases. 
20o of whom took it in pilular form, and 2:32 hypodermically. The ave- 
rage dose was from two to five milligrammes. Tie obtained temporary 
benefit, which seemed to wear off; but when the drug was repeatedly ad- 
ministered, he accomplished many cures. He reports twenty-three cures 
by an average of seven injections. It is a dangerous remedy, however, 
and produces severe gastric symptoms. 

The salts of zinc have occasionally proved valuable in cases of this dis- 
ease; and conium is occasionally efficacious, but its effects are temporary ; 
but I prefer the remedies I have mentioned. I have found phosphorus. 
with cod-liver oil, to be a most valuable curative agent, and in cases where 
everything else failed it has succeeded. This seems reasonable, when 
we consider how much impaired must be the nutrition of the nervous 
matter. 

Da Costa 1 and Mills,' 2 of Philadelphia, have used the bromide of iron : 
but the latter has had very unsuccessful results. In twelve patients t" 
whom he administered the drug, there was no improvement after it- use. 

Dr. Mills says: " It was usually given in plain syrup and water, com- 
mencing with five grains three times daily, as recommended, and rapidly 






1 Med. and Surg. Reporter, Jan. SO, is::,. 

2 riiihi. bled. Times, Sept. 25, L875. 



406 CEREBROSPINAL DISEASES. 

increasing the dose to twenty.. The treatment was continued from two to 
tour weeks. Twenty grains very generally caused vomiting. It seems to 
be a remedy which quickly irritates the intestinal tract." 

Oulment and Laurent recommend hyoscyamin in doses of one-sixtieth of 
a grain, in pill form, at first twice daily, and afterwards more frequently. 
Amelioration is said to begin in eight or nine days. Should the presence of 
worms he suspected, we may either use an injection of quassia and carbolic 
acid solution (gtt. x — ()j) after each stool, or pursue the ordinary santonine 
treatment. The use of ferruginous tonics is generally indicated, and those 
should be selected which are best assimilated and which tax digestion the 
Least. 1 would therefore recommend either the carbonate of iron, or dual- 
ized iron. The addition of digitalis seems to increase their good effects 
quite materially. Chalybeate waters are useful, and sulphur baths are 
recommended by Baudelocque and others. 

Trousseau recommends morphine and strychnine, but I have never seen 
any good results follow the use of the former; of the virtues of the latter 
I have already spoken. H. C. "Wood recommends a tincture made from 
the fresh Leaves of the skunk-cabbage, with which he has had some suc- 
cess. Electricity I have no faith in, except, perhaps, when the so-called 
" general electrization" is used as a cutaneous and muscular stimulant. 
Benedikt has cured many cases by galvanism ; but, as far as I can learn, 
his results are exceptional. 

There are instances where nothing does good. It is well to put the 
patients in a dark room, and keep them perfectly quiet. We will be often 
astonished at the result. Tliere are little, things that must be watched. 
The diet, above all things, should be regulated with judgment. Plenty of 
fresh air and sleep come next, and absolute mental rest must be enforced. 
The school-books and the school-room are to be parted from, and agree- 
able diversions planned. An excellent auxiliary to our medication is the 
salt-bath. A handful of rock-salt in the water, and the energetic' use of 
the rough towel, will infuse a tone and vigor that will soon become appa- 
rent. In conclusion, I must say that decided medication is useless in 
these patients if their personal habits are not looked after. 



PARALYSIS AGITANS. 

Synonyms. — Shaking palsj ; Parkinson's 1 disease ; Trembling palsy; 
Tremblemenl eenile; Chorea senile j Chorea festinans. 

Il i- unfortunate thai BO much confusion c\is!> in regard to the proper 
classification of this tremor of old age. Il has been and is to this day 

confounded with cerebro-spinal sclerosis. 

I shall speak of ii as :i disease of advanced Life, sj mptomatized by paresis, 
involving usually the upper extremities, with tremor which is not increased 
bv roluntan muscular actioV This tremor rarely affects the muscles of 



mi Shaking Palsj . London, 1817. 



PARALYSIS AGITAN8. 407 

the face, except in advanced stages of the disease, and is accompanied by 
festination, and in certain cases by bending of the body forwards, and 
inclination of the chin forwards and downwards. 

Symptoms The extremities first become the seal of tremor, the fin- 
gers being agitated in the beginning ; the hand is next involved, and after- 
ward the arm. This tremor is bilateral, and it may not make further 
advances for some time, but ultimately the head and other limbs are 
included. The tremor may involve one hand before the other, or the Leg 
of the same side may be next affected, then the leg of the other side, and 
next the opposite arm. After a variable time, extending from one to ten 
years, a species of muscular rigidity takes place, so that the head is drawn 
down, and ultimately the body is bent and the head is thrust forward-, or 
the chin is drawn down to the breast. The forearms and hands are flexed, 
and the arms may be drawn to the side of the body. The constant move- 
ments may produce an actual abrasion of the skin by friction of the elbows 
or hands, should the muscular contraction bring them in contact with the 
body. Any attempt at locomotion is attended by what has been called 
•• festination." The patient may rise slowly from his seat, and perhaps 
in the early stapes walk, slowly though awkwardly, by taking long strides. 
but when the muscles of the back lose their power, and the body pitches 
forward, the patient's attempts to preserve his equilibrium result in a 
shuffling gait, and finally he is compelled to run and gladly clutches the 
nearest chair or support to avoid falling. 

The voice is weak and the speech broken and abrupt, and the form of 
interruption has been compared by Charcot •• to that which affects a novice 
in equitation when his horse begins to trot." This interruption is caused 
by the violence of the muscular movements. The patient pitches his voice 
when he begins to speak, and never changes the tone until he has finished, 
so that his phonation is decidedly monotonous. He is greatly fatigued by 
the constant muscular movements, and is restless and inclined to seek new 
positions which may give him ease. A disagreeable symptom is the 
Currence of cramps of temporary duration, which are more common during 
the day. During the tremor the fingers or toe- may be rigidly flexed or 
extended. The face is utterly devoid of expression, but the mind is never 
impaired, and there are no affections of the organs of special sense. The 
tremor in the beginning ceases at night, but in tin 1 established form it i- 
present at all times. 

The termination of the disease may be in death through exhaustion or 
complicating diseases, such as pneumonia, which carried off three cases 
reported by Trousseau. The functions of the bladder and rectum are not 
usually involved, except when the disease has become confirmed. In one 
case Topinard found sugar in the urine, but it is hardly necessary to say that 
this circumstance is exceptional. 

After suffering for a Dumber of years the patient is finally obliged to 
seek hi- bed. sloughs form over the sacrum, and he gradually Binks, the 
tremor, perhaps, moderating slightly before death. 



403 CEREBROSPINAL DISEASES. 

The following interesting- case is one that illustrates the course of the 
disease perfectly : — 

Mr. M., the patient, during his early years led an active life, and after 
following the occupation of a peddler gradually worked his way up to 
prosperity. For years he went about the streets of New York carrying, 
many hours in the day, a heavy pack upon his back, and during this time 
he suffered many privations of food, rest, and sleep, and was exposed to 
the elements, after going home wet and cold. About fifteen years ago he 
firs* noticed the appearance of his present disease. He is a, stout man of 
large frame, and about 7(> years old. The trembling began after slight 
exertion, and continued for some time. It became more pronounced and 
constant during the next two or three years, and he was unable to un- 
button his clothing, feed himself, or \w. his hands. His general health 
did not seemingly sutler, but he was "nervous" and depressed, and fully 
aware of his pitiable state. lie did not tremble so much when lying down, 
but when he moved about or assumed the erect position the hands shook 
and the head shook constantly from side to side. The movements always 
stopped at night, but it was some time before he could sleep. He gradu- 
ally lost power ; the right arm losing strength primarily, and afterwards 
the left. Coincident with the loss of power there was tremor. When I 
saw him two years ago,, I found him seated in a chair in which he had 
difficulty in keeping his place. His upper extremities and head were 
chiefly affected. The head was inclined forwards, and was constantly 
agitated by movements of a rhythmical character, which did not appear to 
be increased or diminished by any act of volition. He could not raise his 
chin, but looked up at me when I entered the room with his son. When 
asked a question, he answered in a tremulous voice, speaking as would one 
who was chilled. His body was curved forwards, ami his arms were semi- 
flexed, the elbows being drawn to the chest; and forcible or voluntary 
extension was impossible. There was no atrophy of the. muscles of the 
arms or forearms, and no decided loss of sensation. The hands were agi- 
tated by the same rhythmical tremors as the head. When ho was lifted up 
he could not walk, and would have pitched forward if not held. In this 
position I noticed that the knees were also affected by the tremor. His 
bladder and rectum did not seem to be involved, at least not as a result of 
the disease, for beyond symptoms of enlarged prostate he suffered no im- 
pairment of function. For the past two years he has needed powerful 
opiates to procure sleep, the movements continuing unless they are given. 
lie swallows with dilliculty, and there is a drain of saliva from the comer 
of his mouth. A.S far a- I can learn there have been no disorders of the 
organs of special sense, and certainly there are now none. His mind seems 
to be Bomewhal affected, as he is Irritable and silly, and his memory is 
deficient. 



1 1 may be stated thai (he affect ion may exist in a modified form ( Parkin- 
Bon'a disease), and thai tremor alone may be the onlj symptom. Festi- 
nation and rigidity are by no means con stan 1 expressions of the affection. 

Causes. — Nothing ie known»jn regard i<» the causes of paralysis agi- 

tans. It ha- followed mentaj distress, or has been preceded by neuralgia 

: L 1 1 ' 1 rheumatism, bul these Beem t<» !»• connected with so many nervous 

thai ii is difficult i<> say just bow much they have to do with the 

of parah jig agitan.-. I lm\e 8660 BOVeia] CaSQS, and in none of 






PARALYSIS AGITANS. 409 

them was there any history of predisposing or exciting canses. We know 
that the disease is rare before the fortieth year, and that the male Bex is 
more often affected than the other sex. 

Morbid Anatomy and Pathology Handheld Jones' and Ham- 
mond 2 are supporters of the doctrine that the affection is purely of a func- 
tional character; and the latter is of the opinion that the paralysis agitans 
of Charcot is a multiple cerebral sclerosis. In an excellent review of the 
recent writings of Charcot and Moxon, which has appeared lately, the 
reviewer says : "There is a certain satiric humor in Prof. Charcot's notice 
of the morbid anatomy of paralysis agitans. lie divides the autopsies 
hitherto made into three groups. In the first group nothing at all was 
found. The second group comprises cases of supposed paralysis agitans, 
which Prof. Charcot considers were in reality sclerosis : and the third 
group contains the case of Parkinson subsequently mentioned, and a 
similar case by Oppolzer, which is treated with similar distrust. There 
are, however, other cases on record which give much more satisfactory 
results. Leyden has reported one in which the agitation was limited 
to the right arm, and a sarcoma the size of a large nut was found in 
the optic thalamus of the opposite side. Murchison and Cayley have 
reported a case in which very definite changes, partly of sclerosis and 
partly of cell growth, were found in the cord; but as in this case 
the symptoms are described but very briefly, it is possible that Prof. 
Charcot would place it in his second group. JofFroy, however, took 
especial care to investigate this point, as to whether the cases were really 
paralysis agitans or insular sclerosis, and he states that two out of his three 
cases were clearly paralysis agitans. In these two cases there was exube- 
rant growth of the epithelium of the central canal and of the nuclei around. 
In the third case, which seems not to have been a very doubtful one. there 
was in addition a sclerosed patch in the medulla." 3 

The pathology of tremor is still so imperfectly understood, and there is 
so much to be said, that it would involve a much more protracted con- 
sideration than the size of this book will permit. We may, however, con- 
sider some of the physiological conditions of muscles which, when disturbed, 
result in the pathological state known as tremor. 

The variation or interruption of any compound entity is followed by an 
inharmonious relation of its parts ; thus a musical sound is the result of a 
number of more or less rapid vibrations and waves, their number influencing 
pitch. If a, catgut string in a state of tension is twanged, vibrations are in- 
duced and a musical tone is produced ; but if a stick be Loosely held against 
the string, without actual pressure being made, the vibrations will bo inter- 
rupted, and a discordant noise will be the result of such contact. It has 
been demonstrated that a visible muscular contraction i-. after all, the re- 
sult of an incredible number of smaller contractions, which cannot be seen 

1 Functional Nervous Diseases, p. 882. 

2 Diseases of the Nervous System, p. 785. 

3 Brit, and For. Med.-Chir, Rev.. Oct. 18 



■410 CEREBROSPINAL DISEASES. 

with the naked eye, but may easily be appreciated with the aid of the 
myographium or some other registering instrument. Upon faradizing a 

muscle this may be experimentally demonstrated. Short breaks are fol- 
lowed by visible contractions of the muscle and movements of the limb ; 
but it' by a proper current-breaker this interruption be repeated many 
hundred times a minute, the intervals will be so short that, though an im- 
mense number of rapid contractions take place, there is but one grand 
contraction of the muscle which is appreciable. 

In the physiological state this coordination (if I may use the word) of 
the minor contractions is so perfect that the muscular movements are steady 
and separated by regular intervals; but when the rhythm is lost, or the har- 
mony destroyed, the smaller contractions will be separated by intervals of 
sufficient length to be seen, and tremor results, the degree of tremor 
being proportionate to the length of the interval. 

The filaments of a tired muscle, the motor centres being worn out, do 
not contract evenly; so, as a consequence, there is a visible tremulous- 
no-. In functional tremor, such as characterizes the disease in question, 
this is undoubtedly the pathological condition. 

Diagnosis The tremor of cerebro-spinal sclerosis may be mistaken 

for that of paralysis agitans. Let us compare the points of difference: — 

PARALYSIS AGITANS. CEREBRO-SPINAL SCLEROSIS. 

Tremor continuous, but not increased Tremor subsides during repose, and 
by voluntary efforts. is always aggravated by volitional at- 

tempts at control. 
Tremor regular and "fine." Tremor "coarse." 

Facial muscles unaffected. Usually cranial nerve paralysis, or 

tremor of facial muscles. 
Runs forward to preserve balance. Only staggers when walking is at- 

tempted. 
Speech slow, or affected by violence Speech-defects those which arise 

of muscular movements. from paralysis. 

A disease of old age, or advanced Usually a disease which appears be- 

lit'e. fore middle age. 

.Mercurial tremor, lead tremor, and alcoholic tremor sometimes resemble 
thai <>f the disease in question ; the former is, however, more violent in the 
morning; the tremor from lead is attended usually by colic and other 
symptoms of plumbism; while no doubt need arise in regard to the third, 
which i- attended by evidences of alcoholism. Post-paralytic chorea may 
he excluded by the history of hemiplegia or some other equally prominent 
organic condition, and the tremor is aggravated by voluntary efforts. A 
functional tremor of a \<'vy light grade, which is simply a personal pecu- 
liarity, is met with sometimes, and should not be magnified to the dignity 
of a disease. This may affect several members of the same family, as is 

ihi case in one example of which I know. The head of the family is a 

vestryman of an Episcopal church, and in passing the plate he sometimes 
i- obliged to exercise the utmosl -elf-control to present the contents from 
being thrown out, and more than once this infirmity has given rise to 



PARALYSIS AGITAN8. 411 

insinuations concerning his habits. His two children, both very young 
and healthy people, are affected by the same tremor. In such a case the 
trouble does not increase with time, and there arc none of the other pro- 
gressive signs of the true affection. 

Prognosis. — The course of paralysis agitans is decidedly progressive, 
though very gradual, and the individual may live for ten, twenty, or even 
thirty years after the appearance of the tremor. Wheu death takes place, 
it is in nine cases out of ten the result of some other disease. J am 
convinced that genuine paralysis agitans is never cured, though it may be 
relieved ; and it is highly important to distinguish simple functional tremor, 
which is not uncommon, from the disease under consideration. This 
functional disorder is amenable to treatment. 

Treatment Ilandfield Jones 1 considers that nothing can be done 

for the disease among very old people when it has become decidedly 
chronic. lb 1 has used electricity, conium, and a variety of remedies. 
" The general tenor of experience in this and in kindred disorders is to 
the effect : (1) that the main indication is to nourish and support the fail- 
ing power of the nervous centres affected ; (2) that this is best accom- 
plished by remedies drawn from the class of sedatives, or by the milder 
tonics. Henbane, conium. chloral, subcutaneous opiates, bromide of potas- 
sium, belladonna, hypophosphites, or phosphorus, cod-liver oil. carbonate 
of iron, and sulphuret of potassium baths, with electricity in one or other 
of its three form-, appear to me the most hopeful remedies, lint steady 
persistence in appropriate treatment is doubtless essential, and the want of 
this may account for many failures. Trousseau's adage should be borne in 
mind. 'A longue maladie, longue traitement. 5 " 

He refers to a cure reported by another observer. The patient was a 
woman, eighty years old. in whom the disease followed severe labor; and 
she was ultimately unable to carry trays or heavy loads. The faradic cur- 
rent used several times effected the disappearance of the tremor. I am 
inclined, however, to consider this case one of functional tremor, and not 
of the grave variety I have described. 

I have used conium with good results, and find that it relieves the patient, 
but after the use of the drug has been discontinued for a few weeks, the 
tremor is pretty sure to reappear. It should be given in doses of the fluid 
extract of from n^v-n^viij thrice daily. 

Elliotson* has cured a case by the carbonate of iron in large doses, and 
strychnine has been suggested, but it is doubtful whether it does any real 
good. 

Galvanization of tin 1 spine, one pole placed over the spine, and the 
other as near a- possible to the point of exit of the spinal nerves, has been 
advised; and in some instances it has improved, if it has not cured, the 
affection. 



1 Brit. Med. Journ., March 8, 18? 

2 Quoted bj Jaccoud, op. cit., vol. i. p. 427. 



412 CEREBROSPINAL DISEASES. 



EXOPHTHALMIC GOITRE. 

Synonyms. — Basedow's disease ; Graves' disease ; Exophthalmie 
cachectique ; Cardiogmus strumosus. 

This interesting disease has received but little attention until within a 
few years, and it is only lately that it lias been considered as a neurosis.* 

Definition. — Exophthalmic goitre is a disease connected with vascular 
excitement and circulatory disturbance; there is not only enlargement of 
the thyroid gland, but an excessive engorgement of the intra-orbital ves- 
Bels, ><> that the eyeballs are pressed forward, giving rise to a hideous 
deformity. 

Symptoms. — The first symptoms of the disease are generally indi- 
cated by violent action of the heart, and great acceleration in the circula- 
tion ; and with this there is hyperemia of the cerebral vessels. Palpitation 
and pain over the left side of the chest, shortness of breath, and flushing 
of the face are other symptoms of this early stage. This early vascular 
disturbance is, perhaps, the first evidence of the disease noticed by the 
patient, but the enlargement of the thyroid gland may have been pro- 
gressing for some time. There may be other early symptoms which ap- 
pear with increased growth of the goitre, and protrusion of the eyeballs. 
These are falling out of the hair of the eyebrows, as well as the eyelashes. 

The heart's action is violent throughout the disease, and the pulse may 
beat from 120 to 140 per minute ; while the temperature is one or two 
degrees higher than the normal standard. There is nearly always a. sys- 
tolic bruit and a carotid murmur. The hand, when placed over the goitre, 
may receive a peculiar sensation, which is produced by the agitation of 
the thyroid by the rapidly circulating blood in the enlarged vessels. 

There is rarely any visual disturbance, although troubles of accommo- 
dation are met with ; and there are no changes to be observed in the retina. 

Digestion is nearly always impaired, and there may be some diarrhoea 
or attacks of vomiting; while sleep is troubled, and the patient sutlers 
greatly for want of rest. 

His appearance is unmistakable. One or both eyes are prominent, and 
Uncovered by the lids ; and the sclerotic is exposed above the eorne;i to a 
great extent. The patient is hypermetropic, and suffers considerably from 

conjunctivitis produced by the irritation of foreign bodies which lodge 
there. 

Dr. Yeo reports two very valuable cases, which are presented in admi- 
rable shape in :i late number of the British medical Journal. 1 In one of 
these ( big. 18 ) there was exophthalmos of the left eye <>nl\ . the goitre being 
on tin- right side. The second case was thus described by \h-. Yeo: "The 
patienl b :i young Bingle woman, 23 years of age, robusl and Btrong-look- 
ing. sic -hows no Bigna o£ the pronounced cachexia (phthisical) bo evi- 
dent in the other patient. But ihe is especially interesting now, as being 



March 17, L877. 



EXOPHTHALMIC GOITRE. 



413 



also the subject of unilateral exophthalmos. In her case the righl eye only 
is prominent. There is very little, if any. enlargement of the thyroid, but 
there is constant palpitation. The pulse has varied during the time Bhe 
has been under observation from 1 ] (i to 1 10. She comes of a healthy 

Fiff. 48. 







Dr. Ycu's Case of Exophthalmic Goitre. 

family, and has always had good health till lately. She first noticed the 
prominence of the right eye about a year ago. All this time Bhe has been 
feeling nervous and excitable. She came to King's College Hospital about 
nine months ago complaining of pains in the back of the head and palpi- 
tation. She stated, also, that she suffered frequently from - bilious attacks,' 
attacks of vomiting which would last a whole day, after which her throat 
would get very large. She complained, also, of frequent profuse perspira- 
tions coming on twice and three times a day. sometimes without any cause 
and sometimes on the slightest exertion. The hands and feet are always 

perspiring, and her hair is sometimes wringing wet." she i- easily 
Fatigued, has lost her appetite, and is much thinner than she used to be. 
She suffers much from dysmenorrhea, and all her symptoms are worse at 



414 CEREBROSPINAL DISEASES. 

her periods. She says her throat was much more enlarged nine months 
ago than it is now. 

There may be double exophthalmos or single, but the double affection of 
the eyes is the rule in the great proportion of cases. 

The eyeball may be pressed back, as the vascular cushion behind is 
soft and yielding; and a peculiar thrill is to be felt. An "arcus senilis" 
lias repeatedly been observed : by Bartholow, 1 who first called attention 
to this change, and by others, among them Thomas. 2 Irritability of 
temper, hysteria, laryngeal trouble, and difficulty of breathing are symp- 
toms which are to be noticed, and towards the end this respiratory em- 
barrassment becomes quite distressing. 

The patient is generally badly nourished, and we may have added to 
the symptoms already described many of those of general anaemia. 

The skin of the whole body may sometimes be of a much darker hue 
than it is in a condition of health, and some discoloration of that covering 
the forehead is often noticed. This discoloration resembles a brown stain, 
and it has been spoken of as "bronze skin" by some writers. Raynaud 8 
lias called attention to the connection between this stain, or vitiligo, and 
exophthalmic goitre, lie gives "five cases of exophthalmic goitre, culled 
from various sources, in the course of which patches of vitiligo appeared 
on various parts of the body. Beyond the observation that vitiligo is 
more common in men than in women, except when congenital, that it 
attacks by preference persons of dark complexion, that it is sometimes, 
though rarely, hereditary, and has a certain analogy to Addison's disease, 
viewed as an imperfect vitiligo, little- has been made out with regard to 
it- pathology. Mr. Hutchinson has pointed out that although no known 
cachexia appears to set up a predisposition to the affection, the symmetry 
of the cutaneous patches is suggestive of some pre-existing general fault 
of the circulatory or uervous systems.* and is opposed to the hypothesis of 
a parasitic origin. Without offering any explanation of the coexistence 
of vitiligo with exophthalmic goitre. Dr. Raynaud thinks that the coinci- 
dence should not be allowed to pass unnoticed." 

Roth 4 reports a case of exophthalmic goitre, the patient being a woman 
fifty year- of age, her menopause having taken place six years before. 
She became debilitated, suffered from palpitation and sweating at night, 
and afterwards there was gradual enlargement of the thyroid gland and 

protrusion of the eyeballs. The pulse was 1*2", and the lem peral lire 

normal. It was impossible for her to close her eyelids. The exoph- 
thalmos was greater on the lefl side, and the thyroid was more enlarged 
on t he opposite Bide. 

Galvanism was used, the positive pole being placed on the upper pari 
ot the sternum ami the negative on the superior cervical ganglion. On 

1 Chicago Journal of Nerypus and Mental Diseases, July, 1875. 
•' Richmond and Louisville Med. Journ., Nov. 1876. 

b-chiv. <"'n.. June, 1875; and London Med. Record, Sept. 15, is::.. 
1 \\ i. n. Med. Presse, 1875, No. 80. 



EXOPHTHALMIC GOITRE. 415 

the right side ten cells produced no sensation, but on the left, six were 
sufficient to produce burning. The current was also passed through the 
buck. The night-sweats and palpitation diminished, and she grew stronger. 
At the end of a month Bhe had gained two pounds in weight, but the 
reduction in size only occurred in the lefl exophthalmos and left portion 
of the thyroid. 

The connection of urticaria lias been pointed out by Bulkley, who 
reports two cases of the disease. One of these is presented: — 

"Mrs , aged 4o, was delicate and sickly when a child. Was married 

at 18 years of age, but separated from her husband after 1 months; sin- 
had a miscarriage at 3 months, and has never been completely well since. 
She is of full habit; bowels and menses regular; tongue coated; pulse 84, 
weak; has had chronic rheumatism. 

"The history of the Graves' disease dates back a number of years — at 
least five years previous to my seeing her. This diagnosis was made by 
a prominent oculist whom she consulted about the projection of her left 
eye. She has been treated much of the time ineffectually by various 
physicians, remaining with each long enough only to experience more or 
less benefit, and then changing. The eyes exhibit clearly the peculiar 
appearance of patients with exophthalmic goitre, the left one being more 
strikingly prominent, and being of but little service for vision, she soon 
losing control of it. The other phenomena of the disease have 1 been present 
for some years — irregularity of the heart's action, and at times severe 
palpitation, and enlargement of the thyroid ; but this is not so very marked. 

"Five years before coming to me she experienced a severe nervous 
shock, and (bites her skin trouble from that period. She states that she 
has not perspired since. She began then to have 'a tine rash and 
redness all over the body,' and itching. This continued about the same, 
oft' and on, for four years, when, after being weak and exhausted, and 
having various hysterical difficulties, the itching became more general, 
and an eruption corresponding to that now existing appeared. Lumps 
would form on the forehead and on various parts of the body; sometimes 
the face and head would appear greatly swollen. 

"When first seen she was in a pitiable state of nervous anxiety: the 
itching of the feet and toes and sometimes of other parts of the body she 
described as agony. At the first visit there was not so much to be >een 
on the skin, but there were a few urticarial blotches on various parts of 
the body and limbs. While under observation, however, she had several 
acute attacks of skin trouble, all of the same sort. On one occasion she 
woke with the upper lip greatly swollen, and with swellings on various 
parts of the body. On the following day, when seen, the whole face was 
swollen and puffy; on the middle of the forehead there was a large erythe- 
matous lump, also one beneath the right eve, and smaller ones about the 
face. The hands were swollen; on the right hand, near the little linger, 
there was an erythematous patch, somewhat swollen and with two small 
vesicles on it. There were also various erythematous and urticarial 
blotches about both hands and wrists; and on the back of the left hand, 
near the thumb, there was a red spot with the skin broken, as it" the seat 
of a former vesicle. The whole surface of the skin burned as it' scalded 

or scratched ; there was no pain on deep pressure. On another occasion, 
a day or two after there had been, according t«> her statement, numerous 



41G CEREBROSPINAL DISEASES. 

swellings on various parts of the body, the remains of several were visible 
on the right cheek, and on the arms there were numerous stains, some of 
them quire dark, as if the parts had been bruised — the remains of the 
lumps; the hands and arms wore manifestly swollen, and there were 
urticarial wheals on the limbs and body." 

The following case is one of unilateral thyroid enlargement, with 
double exophthalmos : — 

Mrs. L. !>., 28, I*. S. ; milliner. Was always well until eight years 
ago, when her present difficulty began. She was then living in New 
York, and actively employed. At this time she noticed the growth of a 
goitre upou the right side of the neck, which pulsated violently when she 
was excited or over-fatigued. She then flushed easily, and often had 
headaches, which were quite intense. These she has now, and her pain 
is of the congestive variety, and diffused. She presented herself at the 
OUt-patienI department of the New York Hospital, complaining of a pain 
just beneath the border of the last rib on the left side, which was quite con- 
stant, but not increased by pressure, or by taking a long breath, or after 
eating. The pain was most severe in the morning, and seemed to move 
oil" towards night. Her heart seemed healthy, as far as valvular lesions 
were concerned, for no abnormal murmur was present ; but there was 
great rapidity of action, the pulse-beats varying from 106-120 per minute. 
The pulse was also quite bounding, and full. The carotids pulsated quite 
strongly, and there was a very marked venous thrill perceptible in the 
jugulars. Upon the right side of the neck, just above the storno-clavicu- 
lar articulation, and extending laterally, there was a tumor measuring 
2J inches in length, and about 2 inches in breadth. The marked pulsa- 
tion of this growth led Dr. Slaughter and myself to suppose at first that 
it wa8 an aneurism, but we were unable to reduce it by pressure, or to 
diminish its size by compression of the carotid; and there was no history 
of injury. The peculiar movement was dwc to the pulsation of tin' carotid 
upon which it rested above, and laterally passed the right jugular vein, 
which was also agitated by the transmitted pulsation of the carotid. 
When the hand was placed upon the enlargement there was perceived an 
Undulatory or •• purring" movement. A'o bruit was heard with the stelho- 
SCOpe, but the tracheal sound was readily perceived. This growth under- 
went variation in its size. Cold weather seemed to influence it in this 
way, and stimulants, or other agencies which increased the blood pressure, 
materially modified its size. 'ldie face was puffed, bloated, and red, and 
the eyeballs were somewhat prominent, while the pupils were dilated, and 
the iris rather sluggish. She was not hypermetropic, and there were no 
other defects noticed. By stead} pressure I was enabled to perceive the 
"cushion feeling" alluded to by medical writers who have observed this 
disease. Her companions twitted her in regard to her fixed -tare, which 
resulted from the exophthalmos. Her ankfes and feet were (edematous, 
and pitted deeply on pressure. Her urinary organs seemed |<> be in order, 

and there were no indications of renal disease. She has noticed at times 
patches of rusty discoloration which appeared aboul her neck and upon 

tie- left side Of her face. Th<— e lasted for several days, anil then hided 

away. She has hud seveafl] minor Bymptoms, such as nose-bleed, which 

OCCUrS even now. every tw<> Or three weeks. Her menses are scant, but 

there is apparently no interior disease. Her digestion is feeble, and Bhe 
i- Blighth constipated. K. Ext. ergotas M. 5jj '• '• ''• 



EXOPHTHALMIC GOITRE. 417 

Causes The disease is one of middle age, and there are about twice 

as many females as males affected. It is connected, in some cases, with 

metrorrhagia, or hemorrhoidal bleeding, or in others with heart disease. 

Examples of traumatic origin have been noted by Begbie 1 and Yon 
Graefe, 3 and others have been apparently of idiopathic origin. The case 
Of the first followed head injury. 

Morbid Anatomy and Pathology. — The observations of those 
who have made autopsies differ greatly. Morel Mackenzie found soften- 
ing of the corpora quadrigemina and the posterior part of the medulla. 
The heart was not much affected, there being only slight atheromatous 
deposits on the mitral and aortic valves, witli thinness. Other observers 
have found hypertrophy of the heart and insufficiency of its valves, but 
in other cases there were no heart lesions whatever. The thyroid gland 
has been found to contain enlarged vessels, and the orbits an increased 
quantity of fatty tissue. In one of Begbie's cases there was sinking of 
the eyeballs in the orbital cavities after death. 

3Iuch discussion has taken place in regard to the pathology of the 
affection, but recent investigations point to the nervous origin of the dis- 
ease. The cervical sympathetic has been found to be altered, and 
numerous instances of the change have been brought forward by Reck- 
linghausen, 8 Trousseau, 4 Archibald, 5 and others. Notwithstanding this 
explanation (the sympathetic origin), others contend that it is a disease 
of the brain ; and still another theory is accepted by those who consider 
it a cardiac disease per se. The nervous origin seems to me to be that 
which is most acceptable. Not only does the use of galvanic treatment, 
which cures the disease, suggest this neurotic character of the affection, 
but the hysterical phenomena mentioned by Basedow, and noticed fre- 
quently by others, are certainly significant. 

We may, I think, consider the disease to be dependent upon an affection 
of both the sympathetic and spinal accessory nerves. The condition of 
the vessels of the thyroid gland and those of the orbit, the flushing of the 
lace, and general disturbance of digestion, are probably due to the altered 
function of the first-mentioned nerve, and the heart excitement is a con- 
sequence of deficient innervation of the accessories. 

Diagnosis There need be no mistake made in the diagnosis of this 

affection from simple goitre, and after this is accomplished there is 
nothing else suggested. One inspection of the enlarged thyroid, and the 
protruding eyeballs, and the detection of the vascular excitement, are 
sufficient to enable us to say that the case is one of exophthalmic goitre. 

Prognosis. — A cure is recorded by Cheadle; another by Mackenzie,' 



1 St. George's Hospital Reports, vol. iv., 1869. 

2 Archiv flir Ophthal., L857. 

3 Deutsche Kliuik, L863. 

4 Trousseau and Peter, Gaz. Hebdom., 1864. 

6 Med. Times and Gaz., L865. 6 Op. eit. 

27 



41 S CEREBROSPINAL DISEASES. 

who also reported a death. Bartholow 1 has cured three patients; Ham- 
mond 9 four, and reports one death. Dr. J. P. Thomas, 3 of Kentucky, 
details a very interesting ease which ended fatally in five years. Very 

little can be said in regard to the character of the disease, but it has heen 
cured in certain instances in a year or two. It may last for several years, 
however, and is essentially a chronic affection. Trousseau, Charcot, and 
Corlieu 4 report cures, in which pregnancy, uterine hemorrhage, or some 
such complications occurred during the disease, influencing its disappear- 
ance 

Treatment Galvanism, it seems, has succeeded admirably, and 

Bartholow has cured three eases by this agent. Chalybeate preparations, 
digitalis, ergot, and cod-liver oil are all excellent remedies (FF. 6, 8, 21, 
16), If galvanism be used, we should bring the sympathetic nerve under 
its influence by placing one pole (the positive) at the angle of the lower 
jaw. and apply the negative over the epigastrium. 



1 Op. cit. 2 Op. cit., p. 79: 

3 Richmond and Louisville Med. Journal, 187 7. 
1 Rep. by Jaccoud, vol. i., p. 672, 2d edition. 



NEURALGIA. 419 



CHAPTEE XY. 

DISEASES OF THE PERIPHERAL NERVES. 
NEURALGIA. 

Synonyms (See special varieties.) 

Definition. — Neuralgia may be defined as "a disease of the nervous 
system, manifesting itself by pains which in the majority of cases are 
unilateral, and which appear to follow accurately the course of particular 
nerves, and ramify sometimes into a few, sometimes into all, the terminal 
branches of those nerves." 1 

Neuralgia is essentially the result of lowered vitality, and is never a 
consequence of any sthenic condition. This is proved by the circum- 
stances under which it occurs; it taking its origin from general debility. 
rheumatism, syphilis, or malaria, or some other disease which produces a 
cachexia. Anstie very justly considers that it is the first expression of a 
condition which later on becomes paralysis — one being a partial disturb- 
ance, or cutting off of the nervous supply; and the other a complete inter- 
ruption of the nervous force; and it is a familiar fact that neuralgia very 
often precedes loss of power in parts supplied by an affected nerve. 

Neuralgia is, then, a disease in which pain is the prominent symptom, 
and with which circulatory, trophic, and motorial disturbances may be con- 
nected. 

Pain Neuralgic pain is quite distinct from that of any other disease. 

It is not at all like that of neuritis, which is constant and aggravated by 
pressure, but it is paroxysmal, and is characterized by a stage of increas- 
ing intensity and rapid recurrence, and by a second stage of ki wearing 
out" or subsidence. It appears suddenly, disappears, and returns, being 
broken by a period of rest. These breaks or intervals of remission be- 
come shorter as the attack increases in severity, until the pain seems almost 
continuous. AY hen the climax is reached, the intervals grow in Length, 
and the pain diminishes in severity, and finally subsides. Repeated neu- 
ralgic attacks leave the nerve in a hypenestlietic condition, so that at par- 
ticular points it is tender and sensitive to pressure. 

These foci of exalted sensation have been called by Yalliex'-' " le> points 

douleureux," and correspond to the points of emergence of the nerve from 

its foramen, or at a point when it passes from a deep to a superficial course. 
The terminal ends of nerves are much more often the seat of this tender- 
ness than any other part. The external ramifications of the SUpra-Orbital 

branch of the tilth or the small filaments of other nerves — the ulnar and 

1 Anstie, Neuralgia, etc.. p. t i. 2 Traite* dea Neuralgies, Paris, 1841. 



420 DISEASES OF THE PERIPHERAL NERVES. 

radial for instance — are not rarely painful to pressure. These painful 
points arc met with very frequently in cases of facial neuralgia. A gen- 
tleman who consulted me sonic time ago presented this indication of facial 
neuralgia, there being several hyperaesthetic spots in the roof of his mouth, 
and his gums on one side were exquisitely tender. 

Circulatory disturbances , of a quite marked character, are pronounced 
features of the neuralgic attack. The pulse at first is irritable, small, and 
quite rapid. A species of fluttering palpitation is also present, and the 
surface is pale and cool. In the later stages of the attack, after the pain 
ha- grown decided, the face becomes flushed ; the pulse soft, full, and 
quite bounding ; and the eyes may be suffused and bloodshot, should the 
attack be one of facial neuralgia. 

During this stage, and after the subsidence of the pain, the patient may 
sweat profusely. 

Trophic Disturbances. — These may be connected with the acute pa- 
roxysms, or may result from repeated attacks. Among the former may be 
pemphigus, and herpetic and bullous eruptions ; and among the latter, loss 
of teeth or hair, or alteration in the coloring matter of the hair, atrophy 
of muscular tissue, and various cutaneous changes. Charcot and Weir 
Mitchell, as well as various writers upon dermatology, have called atten- 
tion to the connection of aggravated neuralgic pain, with various cutaneous 
diseases. The most striking of these neurotic skin diseases is herpes 
zoster, in which are eruptions of a vesicular character, a cluster of patches 
being found here and there along the course of the affected nerve. The 
pain precedes the appearance of the eruption, and may continue during its 
existence, and lor some time after, or there may remain a pruritus, limited 
to the parts which have been the seat of eruption. The neurotic character 
of this complication may be proved by its very rapid disappearance after 
galvanization of the affected nerves, 91* administration of large doses of 
quinine. 1 The other trophic alterations, which are secondary, will be con- 
Bidered at a later period. 

Motility. — Connected with some forms of neuralgia are certain conditions 
of spasm. In a form of facial neuralgia which has been known as tic 
epileptiform or tic douloureux, tonic spasm of the eyelid or of the masseter 
muscles is present as a decided symptom. Convulsive movements of the 
legs, 'ine to spasms of the flexors, have also been observed in sciatica by 
Anstie; but in cases in which I have noticed this symptom,il seemed 
rather a resull of excessive pain, and an effort upon the part of the patient 
to relax the pressure upon the affected nerve. Local spasms are quite 

eoiiiinoii ; and the muscles of the face, Of the trunk or limbs, and the 

vomiting of sick headache, are varieties of spasmodic action which may 
be cited a- examples of this kind. In a case lately under treatment, I 
have been reminded of a condition which I have several times observed 
— a species of heaxi pain resemming that of angina pectoris, and connected 
with facial neuralgia. With this pain there would be spasmodic contraction 

1 A form of -kin disease lately denominated pompholyx by Dr. A. 11. Robin- 
ion, "i' Ni-u fork, is ;m example of ;i neurosis of this kind. 



NEURALGIA. 421 

of the muscles of the thorax. Mitchell 1 '* has encountered from time to 
time certain forms of neuralgia, accompanied by muscular spasms and 
extravasations of blood in the affected part. He relate- three cases, all 
occurring in females, and explains the circumscribed hemorrhages by 
nutritive changes in the walls of the vessels, occasioned by conditions of 
the nervous system analogous to atrophic changes in the skin and nails 
in nervous diseases." 

Valliex has divided the neuralgias into the superficial and the visceral, 
and classifies them as follows : — 

A. Superficial. 

1. Neuralgia of the fifth nerve (trifacial or trigeminal neuralgia). 

2. Cervico-occipital. 

3. Cervico-brachial. 

4. Intercostal. 

5. Lumbo-abdominal. 

6. Crural. 

7. Sciatica. 

B. Visceral. 

1. Uterine or ovarian neuralgia. 

2. Neuralgia of the urethra. 

3. " " bladder. 

4. " " rectum. 

5. " " testis. 

6. Hepatic neuralgia. 

7. Neuralgia of the heart. 

8. " " stomach. 

9. Laryngeal and pharyngeal neuralgia. 

Among the first group the most important is neuralgia of the fifth nerve, 
which may also exist with a motor complication, as tic epileptiform, or 
with gastric complications, as migraine or " sick headache.' 

FACIAL NEURALGIA. 

Synonyms Face-ache; Fothergill's face-ache; Prosopalgia; Tri- 
geminal neuralgia; Tic douloureux ; Migraine; Sick headache. 

The supra-orbital branch may be alone affected, and the pain confined 
to the brow and top of the head, or it may be quite generally diffused 
over the face and head, the three branches being involved. The first 
division of the nerves is, however, the most common seat of neuralgia; 

but it is not unusual for an attack to begin above, and finally extend to 
all of the divisions of the nerve on one side. 

Migraine, or "sick headache," presents the following features: The 
attack may be preceded by some chilliness, pallor, and uneasiness, and is 

1 American Journ. of Med. s <-i., Iviii. 1G. 



422 DISEASES OF THE PERIPHERAL NERVES. 

ushered in by a twinge of pain, which begins just above the eye on one 

side, and radiates over the head. The pain is often erroneously referred 
by the patient to both sides of the head, when, in reality, but one-half is 
affected. Deep-seated orbital pain, photophobia, hemiopia and nausea, 
with an irritable, thready pulse, and increase of pain, immediately usher 
in the attack, which rapidly increases in severity; the pulse alter a while 
losing its asthenic character, and becoming full and bounding. The 
patient's bice becomes Hushed, and his skin red and sweaty, and in rare 
cases Hi*' -wealing is confined to one side of the face. The paroxysms of 
pain, which at first were separated by intervals of relief, next become 
almost continuous, but after a time, during which the patient may feed 
like vomiting, they become less severe, and finally, after his stomach has 
been emptied, may disappear altogether. The features of an attack of this 
kind are too familiar to need elaboration. The following case will serve as 
an illustration : — 

Mrs. (i. is a delicate, hysterical woman, who devotes most of her time 
to duties of society. Her domestic affairs are worrying, and the constant 
excitement of entertaining, late hours, and the management of several un- 
ruly children, have so worn upon her that now, at the end of the winter, 
she is anaemic, " run down," and suffers from want of appetite, insomnia, 
and general debility. About twice a week, at irregular times, she suffers 
in the beginning from light pains, radiating from the right eye, and over 
the head, which become quite severe, and increase 1 during the next hour 
or two. She usually becomes cold, and bundles herself up in shawls and 
wraps. Her eyelids feel heavy, and the "skin covering" her "face feels 
as if il were drawn tightly." She is nervous and irritable, and cannot 
bear the presence of her children, and is sometimes so depressed that she 
bursts into tears. She has a vague dread of some trouble, the character of 
which she does not know. The pain increases in severity, and becomes 
almost unbearable. Her eyes are hot, ;yid "it seems as if a peg was being 
driven in from behind." Her face becomes very hot, and her temporal 
vessels throb. The slightest step she may take in walking so jars her head 
that it gives rise to intense pain. She " feels as if" her " head would split 
open." She cannot look out of the window, but lies Upon her bed. and 
buries her lace in the pillows. Nothing seems to relieve her. She may 
lie BO for hours, panting for breath, and pressing her aching head. After 

a variable time, sometimes two hours, sometimes a day, the pain is dimin- 
ished somewhat, and she becomes nauseated ; not because food lies undi- 
gested, for she has taken none for some time, bul the vomiting is of a 
purely cerebral character. She attempts to vomit, bul cannot bring up 

anything. The effort at retching jars her body, and increases the pain. 

After this Btate of affairs has lasted for some little time, she becomes 
exhausted, and falls back upon the bed, sweating profusely. The pain 
grows \<i\ much less Bevere, is dull and throbbing, and finally she sinks 
into ;i deep Bleep, from which she awaken.- somewhat relieved. 

The variations in pain and circumstances which give rise to the disease 
have led different observers^© apply Buch names as " rheumatic," " hys- 
terical," "sympathetic," "organic," " syphilitic," and " clavus." These 
term- have little value, and ii seems that a nomenclature based upon the 
anatomical situation of the neuralgia is all that is needed, and it certainly 



NEURALGIA. 423 

would do away with much confusion. Facial neuralgia, unless it be due 
to temporary exciting causes which may be readily removed, i- rather an 
obstinate affection. It may tab- a periodic character, especially if it be 

connected with malaria; or it may be hut.- intense at night, should it be 

rigin. The true attack rarely lasts beyond a few boors, hut 

attacks (especially of tic-douloureux) may be so frequent as to become 

almost continuous. The tendency i<. I think, tor th»- disease t<» become 
firmly rooted, ami to increase in severity. If there be a rheumatic mala- 
rial, or anaemic form, there is no reason why the disease should not subside 
when these morbid conditions an- removed. As t<> davus, in which the 

mpared to that which would probably follow the dri\ ini: of nails 
through the skull, it may be said that this is an hysterical condition, ami 
atients' descriptions are based upon the workings of a disordered im- 
agination. 

Tl. sry few cases of facial neuralgia in which all the branches 

may not he involved at some time or other. If the neuralgia be confined 
more particularly to the first and second branches of the fifth, the temples 
and fore: r eyelid, root of the nose, and the orbits will he the 

ts at which the pain will be the mo-: 3 ihaehe. above and 

. will indicate involvement of the middle and lower branches, and if 
the lingualis be affected, which it quite rarely is, the tongue will be the 
lent pain. The painful points are to be found principally 
the supra-orbital notch, the infra-orbital foramen, the •• malar point," 
or in the roof of the mouth, over the mental foramen, and in front of the 
ear. During the attack it is not uncommon to find hypersecretion of sa- 
liva, that fluid passing from the angle of the mouth in great quantity, and 
when the supra-orbital and infra-orbital branches are involved there may 
ling profuse lachrymation. 1 Erb 1 has called attention to 
sional increase of secretion from the nasal mucous membrane. 
This has I rred by Vulpian to irritation of one of the sphenopalatine 

_.ia. The patient is nearly always excited and irritable, and if the 
xysms be of frequent occurrence he suffers from insomnia, and is en- 
tirely unfitted for his daily occupations. It must not be supposed that the 
Yoniitinjr of migraine has any direct connection with the condition of 
_ stion. The attack- are. however, aggravated by the [ r - ■:" un- 

i« gtl od in the stomach. 

The deep neuralgias of this nerve are very obstinate, and often beyond 
the r ny treatment. This is notably the case when the superior 

maxillary or it< orbital branches are affected. The ocular symptoms 
then rmidable description, and life to the patient i< a burden 

indeed. 

The following i- one of the most inveterate - a neuralgia <>f this 

kind I have ever observed. The patient's trouble began in 1863, while 

- hool, and then affected the superior maxillary and infra-orbital 



S onetimes there i- spasmodic closure of the orifice of the lachrymal duct. 

i. ii. 



424 DISEASES OF THE PERIPHERAL NERVES. 

branches of the fifth nerve. His sufferings were intense, and after trying 
almost all forms of treatment, and consulting medical men in Europe and 
in this country, he consented to subject himself to an operation for exsec- 
tion. The history he brings, which was taken by the house surgeon, Dr. 
Peale, of Chit-ago, details the surgical procedures undertaken. 

" Patient has for a long time suffered from neuralgia of supra- and infra- 
orbital nerves, and the superior trochlear nerve. Prior to this he had a 
closure of the lachrymal ducts of both sides. He had been in Central 
America, where he was exposed to severe forms of malaria. About two 
years ago. Dr. Strawbridge, of Philadelphia, cut off the supra-orbital 
nerves at their point of exit from the supra-orbital foramen. In either 
eye there is loss of accommodation, and a high degree of hypermetropia. 
Prof. Holmes, of this city, after an ophthalmoscopic examination, told 
him that the veins of the retina were diminished in size. 

He still suffers intensely with the infra-orbital nerves, and comes in de- 
siring to have them excised. He receives 3J grs. morphia, hypodermically, 

eaeli day. 

Dec. 18, 187G. An incision made downward from the location of each 
infra-Orbital foramen to the length of one inch through the tissues of the 
cheek, the nerves raised on a blunt hook, stretched well out, and chipped 
off at their point of exit. Ether used as the anaesthetic, collodion and silk 
sutures to approximate the edges of the incision. 

Wuli. Patient suffering from intense pain referred to outer edge of right 
lower eyelid. 

23c?. Considerable cellular inflammation of right side of neck and face. 

26tk. Considerable discharge of pus from incision on right side of face ; 
swelling very much diminished. 

29th. Discharge of pus from both incisions has now about ceased ; con- 
siderable cellular inflammation of right side of face in parotid region, lie 
claims he has still the neuralgic pain, but deeper in the infra-orbital re- 
gion. 

Blst. Considerable swelling and a great deal of tenderness on either 
side of the neck below the jaw. Patient cannot move the jaw. 

Jan. .">, 1 s 7 7 . Pace continues swollen, and very painful; thinks he still 
has the old neuralgic [tain on right side. Quantity of opiates in 24 hours 
considerably diminished. 

'2\)th. Patient again placed under the influence of ether. An incision 
made on the right side in the site of the old one, and the nerve raised on 

a blunt hook and divided. Following (he operation the pain became 
Severe, and the hemorrhage excessive. For a, couple of hours all Borts <>!' 
efforts were made to stop it, and finally we were obliged to resort to ol. 

terebinth, and ferri persulph. These, with compresses bound on as best 

we could, checked it so thai it only oozed. A large quantity of anodyne 

was required to allay pain. 

30th. There has been no further hemorrhage. Morph. pro re nata, 
Feb, 2, AH dressing removed without hemorrhage; wound left open 

and suppurating; dressed with carbolic acid ; pain controlled with morph. 
\ih. Complains of pain insight temple. 1*. M. Severe headache; 

w ound dressed t wice a day. -* 

1 \lh. Patient had been doing well until yesterday. 'There was a. hem- 
orrhage from the wound in the morning, controlled by syringing with 
(••.Id water. Last night another verj severe hemorrhage; used ^\\y ferri 



NEURALGIA. 425 

persulph. Has had three hypodermic injections of | gr. morph. each, daily. 
Ordered iodoform to be sprinkled in wound. 

March 27. At 3 P. M. patient was etherized, and Prof. Bogue pro- 
ceeded to resect the orbital branch of the superior maxillary nerve A 
circular flap begun in the old cicatrix on the right side, and curving 
backwards, laid ban; the molar bone. An opening was then made through 
its quadrilateral surface with a trephine into the antrum ; the floor of the 
orbit was then gouged away and the nerve hooked up and ruptured. 
There was, following this, hemorrhage. A plug of sponge was then 
stuffed into the antrum and left. In the evening then- was a severe 
hemorrhage from the nostrils and mouth ; the nostrils were plugged. 
Later in the evening the sponge and plug were removed ; the antrum 
washed out ; there was a brisk hemorrhage. MonsePs styptic was freely 
injected ; finally the antrum was again plugged with sponge soaked in the 
same solution. The eyeball was noticed to project considerably more; 
than its fellow, but the sight was not much impaired. Patient lias had, 
till the present time (10 A. M.), morph. gr. iij, by hypodermic injection. 
This morning complains of great pain in the eye and upper jaw. Plugs 
not removed. Ordered whiskey and morph. to allay pain. P. M. Pulse, 
76; temp. 103°. 

30th, A. M. Pulse, 72 ; temp. 100°. 

On yesterday evening the sponge plugs removed from the wound ; no 
hemorrhage occurred ; they were not replaced ; water-dressing continued 
through the night. This morning the wound is suppurating slightly ; 
face not sw r ollen quite so badly. Patient has had one grain morph. by 
hypodermic injection every 4 hours for the past 48 hours. Water-dress- 
ing continued. Patient still complains of great pain in the right eye ; 
swelling is considerable ; eye closed, with conjunctiva protruding from 
between the lids. A pledget of lint saturated with alcohol was laid in 
wound, and water-dressing continued. 

April 1. Is feeling better; wound is suppurating considerably; is not 
swollen so badly ; plugged with lint saturated with alcohol, and the cold 
compresses continued. 

3d. The surface of the wound is covered with healthy granulations. 
The eye very much improved ; can open it ; can distinguish objects at some 
distance. 

4th. The patient's condition rapidly improved. 

Q>th. Cavity granulating finely; appetite good; everything appears fa- 
vorable at this time." 

The patient came to New York and consulted me October 17, 1877. 
In spite of all the surgical operations the pain is as severe as it ever was, 
the focus of intensity being evidently the orbital branch. The eve is 
without sight, but no retinal changes can be discovered, except paleness 
at the fundus. The conjunctiva, is injected, and the eye is suffused. I 
gave him two hypodermic injections of morphia, of one grain each, within 
an hour, but none of the physiological effects followed, and the pain re- 
mained unabated. Nothing remains to be done but deep section oi' the 
nerve. 

A formidable neuralgia is that connected with spasm of tin 1 facial 
muscles, which has received the name of tie douloureux or tic epilep- 
tiform. The former term is that applied by Benedikt, and has been 






428 



DISEASES OF THE PERIPHERAL NERVES. 



generally accepted by most writers to express the violent and sudden 
twinges of pain which are accompanied by very forcible spasms of the 

facial muscles. These spasms may be of varying degrees of severity. 
The eve may be lightly elosed during the paroxysm, or the face violently 
drawn to one side. The attacks are generally supposed to be con- 
fined to those individuals in whom there is a neurotic predisposition; 
and Erb, Eulenburg, and others consider tic douloureux to be a disease of 
central origin, which seems very probable for some reasons, but not so 
much so when we take into account the fact that in some cases the disease 
may appear and disappear, there being occasionally a long period of qui- 
escence, and then a relapse. Anstie considers that the spasm is not di- 
rectly connected with the pain, but is rather inclined to look upon it as a 
coincidence, or as a result of the epileptic tendency, the pain and epilepti- 
form spa-m being separate expressions. 

A very interesting case, to which I have already casually alluded, was 
sent me by my friend Dr. Sayre, of New York. 

Mr. K. had for ten or twelve years suffered from neuralgia of the fifth 
nerve of the right side 1 . His habits had been very good, and there was no 
history of syphilis, nor any evidence that it had existed. About ten years 
au<>. after exposure, he first noticed the commencement of his trouble, 
and at this time there was no facial spasm or very decided pain ; his 
attacks, however, which, during the first two or three years, occurred at 
intervals of two or three months, became much more frequent, and, within 
three years, have become almost continuous, so that there is rarely an in- 
terval of live or ten minutes between each paroxysm. Sleep is utterly 
impossible, and he has been obliged to resort to an immense quantity of 
Stimulants lor the purpose of procuring rest. 

lb- tells me that very often he drinks a pint of whiskey before retiring. 
During his visit he had several attacks of tic, during which his face was 
drawn up and agitated by clonic spasm of the muscles of the right side; 
these attacks lasted one or two minutes, during which his fact' became 
flushed, his eyes injected, and from the corner of his mouth trickled a quan- 
tity of saliva : the gum was \cry tender, and painful points before alluded 
to were found to be \cry sensitive. Numerous painful points were also 
found upon the scalp over the supra-orbital notch, and at different points 
over the temporal bone. Before I saw him he had been under several 

varieties of treatment, but none afforded him the least relief. 



CERVICO-OCCIPITAL NEURALGIA. 

\\ I ien th«' posterior branches of the upper cervical nerves are the seat 
of neuralgia, the patient will complain of pains beneath the occiput) be- 
hind the ear, and sometimes at the under part of the lower jaw. The 
pain hi ili«' base of the occiput is mosl Beverej bul when the neuralgia in- 
volves the anterior nerve branches, and pain appears behind the ear and 
over the lower pari of the face this affection maj be mistaken for neu- 
ralgia of the fifth pair. The pain is often insupportable, and is of a parox- 
ismal character. Ii is, on the other hand, of a localized form, and so 
constant in some cas< - that the medical man may be led to suspect infiam- 



NEURALGIA. 427 

matory conditions of other parts. During the active pain the patient may 
be unable to turn his head or open his mouth, and any muscular move- 
ment is attended with distress. The skin may be either hyperaesthetic or 
anaesthetic, but more often the former, and I have had patients who were; 
unable even to bear the pressure of a collar or other neck gear. The skin 
feels to the patient as if it were tightly drawn over the tissues beneath, 
and it sometimes may be red and appeal- swollen. The hyperesthesia, 
when it involves the scalp, is so distressing that the patient is unable to 
place his head upon the pillow, or wear a hat unless it is much too large 
for him; and heat seems to increase the discomfort to a marked degree. The' 
post-cervical muscles may be the seat of cramps, during which the pa- 
tient's head is drawn backwards or laterally downwards. Painful points 
may be found in two or three situations, but most frequently where the 
great occipital nerve emerges. The spinous processes of the upper cer- 
vical vertebrae are often the seats of painful spots, and it is not rare to find 
that distress is caused by pressure at different places over the occipital bone. 

CERVICO-BRACHIAL NEURALGIA. 

A form of attack manifesting itself in severe pains, which shoot down 
the arms, hands, and back of the neck. Exquisite cutaneous hyperes- 
thesia is by no means a rare accompaniment, the skin being so tender to 
pressure that the slightest touch of the clothing will produce intense suf- 
fering. The distribution of pain corresponds to the parts supplied by the 
lower cervical nerves or regions which are innervated by sensory brandies 
of the brachial plexus. 

Erb 1 has given a diagram which demonstrates the districts of pain, and 
their source of supply, which may be made use of in tracing the course of 
the affected. nerves. (See page 441.) 

My attention has been directed by Dr. Burral to a condition of neu- 
ralgia which is often mistaken for the so-called muscular rheumatism, and 
is probably due to an involvement of the circumflex as well as the pos- 
terior thoracic. The pain is not nearly so acute as that of some of the 
other neuralgias; for example, the facial variety. It is dull and terebrat- 
ing, and resembles the agonizing though temporary pain which follows a 
blow upon the popularly called "funny bone," or ulnar nerve, in its ex- 
posed position at the internal condyle. The pain travels down into the 
hand, and may be attended by a spasm of the muscles. There are points 
of tenderness which are extremely numerous. Pressure made over the 

supraclavicular space, just below the lower angle of the scapula, at the 
exposed portion of the ulnar nerve at the elbow, and at the points of emer- 
gence of the superficial nerves of the arm and forearm as they pierce 

through the fascia, gives rise to pain. Occasionally there are tender spots 
over the cervical vertebra 4 . The skin of the arm is often cold, and areas 

of capillary emptiness are t«> be observed either during an accession of 
1 Ziemssen's Encyclopedia, vol, \i. p. L46. 



4J< DISEASES OF THE PERIPHERAL NERVES. 

pain or between the attacks. In rare instances it is not unusual for tro- 
phic alterations to be manifested. In a patient under observation the 
right hand is reduced in size, the skin is dry, puckered and livid ; the 
Lines of flexure of the fingers and hand are red, and much deeper than 
upon tin- other side of the body; and the nails are crenated and irregular. 
Erb alludes to an excessive sweating of the finders. This form of neu- 
ralgia is decidedly inveterate, and when well established is attended by 
nocturnal exacerbations. The use of the affected hand is sure to aggra- 
vate or precipitate an attack, and changes of temperature act usually in 
tli«' same manner. 

A gentleman sent to me by Dr. Ives, of New York, had suffered in- 
tensely for a number of years, and his pain had become almost constant. 
When he neglected to cover his arm with cotton batting, but permitted 
hi- coat sleeve to come in contact witli the skin, he would be in utter 
misery, bo that he was obliged to cover it with some soft substance. He was 
very cautious in selecting a position at night, as the arm, if unsupported, 
dragged the muscles of the shoulder sufficiently to produce a paroxysm. 

INTERCOSTAL NEURALGIA, OR PLEURODYNIA. 

This is often mistaken for pleurisy. It is characterized by a pain which 
encircles the body, and may be referred by the patient to the region 
bounded by the crest of the ilium below, and the thorax above; but it 
more commonly affects the lower intercostal nerves. The pain is always 
one-sided, and is dull and continued, but may sometimes be sharp and 
paroxysmal, radiating from the spine anteriorly. The skin is hypencs- 
thetic, and this is particularly the case if the neuralgia be attended by 
herpetic patches, 'flic painful points are chiefly over the inter-vertebral 
foramen, and where the nerve pierces*the muscles anteriorly. The rectus 
muscles contain painful spots ;l t the points where the lower intercostal 

nerves pierce the investing sheaths. The patient during the paroxysm 
inclines his body to the affected side, as it were to relax the muscular 
strain; he perspires freely, and his face wears a scared and anxious ex- 
pression, suggestive of great suffering. His breathing is "catching" and 

-hallow, and attended by the least possible movement of the thoracic 
walls or diaphragm. 

-i i \ I l( A. 

Sciatica is perhaps, next to facial neuralgia, one of the most trouble- 
some and familiar neuralgias. It rarely begins suddenly, but has a, 

gradual onset, attended by a variety of disagreeable and annoying symp- 
toms. Cutaneous hyperesthesia, -light fatigue after walking, and "sore- 
ness," ;i sensation of dragging or of heaviness of the leg and foot, and a 
number of minor bi mptoms of a vague character precede the actual pain. 

Thifi ifl exceedingly Bevere, and may exisl in ;i dull form, and during its 

continuance there maj be paroxysms consisting of twinges or "darts" 



NEURALGIA. 429 

shooting down the back of the leg. Should the patient, while Bitting, place 
his thigh so that the nerve shall be pressed against the edge of the chair, 
the paroxysm may be precipitated. Anstie has divided sciatica into three 
varieties, one of which occurs during comparatively early life, and is con- 
nected with hysteria. It is dependent generally upon over-fatigue, and 
affects anaemic people. It is the form which attends irregular menstrua- 
tion, and the pain is quite Bevere. In this variety I have rarely found 
any painful points. 

Before the fourteenth year neuralgia of the sciatic variety is very un- 
common. In 124 cases collected by Yalliex, none were under seventeen 
years of age. 

Sciatica of the second variety is a disease of adult life, ami i< a result 
either of exposure, or some Buch cause as continued pressure of the nerve 
through sitting in an uncomfortable position. It is not rare among busi- 
ness men, or clerks who sit upon high wooden chairs or stools, and who 
generally do not support their legs by placing the feet upon the floor or the 
rounds of the chair. Anstie connected this " middle-aged sciatica " with 
premature decline, and states that the patients have rigid arteries, gray 
hair, and the circus senilis : but I do not consider that these indications of 
decay have any very decided bearing upon the sciatica, especially in the 
form last mentioned. It strikes me rather that the causes which produce 
the disease, with the exception of dissipation and perhaps syphilis, gout, 
or like affections, would be local. Some of the most intractable cases 
of sciatica I have ever seen were persons who were apparently in good 
general health. The presence of " painful points " is highly characteristic 
of this form. Foci of tender nerves may be found corresponding with 
the emergence of the sciatic nerves from the pelvis ; and also at various 
points corresponding to the cutaneous distribution of the posterior branches, 
a- well as just below the crest of the ilium. Points of tenderness may be 
also found at various situations in the course of the nerve at the back of 
the thigh ; sometimes in the popliteal space, or at the head of the fibula, 
and in the depression below the external and internal malleoli. Atrophy 
of the muscles of the thigh is not a rare consequence of the neuralgia in 
old cases, and is sometimes preceded by paresis. Tactile sensibility is 
diminished, and areas of anaesthesia or blanching of the skin are occa- 
sional results of a continued siege. The paresis of sciatica is of gradual 
appearance, and the patient may at first slightly drag his leg or limb. In 
some of the old cases the least movement of the limb is attended by pain, 
which is referred by the patient to the point where the sciatic nerve leaves 
the pelvis. Such atrophy may follow inactivity. 

A curious feature of the disease in some cases is the appearance of pain 
in different parts of the limb. In the case of a Cuban gentleman who 
came to me for advice, I found that then' were two districts of pain: one 
of which included the upper pari o\' the sciatic, the pain never passing 
below the middle third of the right thigh ; the other situated at the outer 
side of the leg oi' the same Bide. 



430 DISEASES OF THE PERIPHERAL NERVES. 

CRURAL NEURALGIA. 

When the pain is confined to the anterior and lateral parts of the thigh, 
it is properly included in the ca^cs called by this name, but the region 
supplied by the crural and its branches, viz., the inner surface of the thigh 
and its anterior aspect, as well as the inner part of the leg and foot, is 
more often the seat of pain in the lower extremity than any other part, 
excepl that innervated by the great sciatic. This pain is paroxysmal, 
very severe, and. like that of the cervico-hrachial variety, most intense at 
night. The inner part of the leg and foot are most commonly implicated, 
and there is a subacute variety of pain which exists between the parox- 
ysms. Walking and muscular movements of any kind are painful, and 
the patient may find it necessary to use a crutch, or else is obliged to keep 
quiet. Foci of tenderness may be detected at the point where the crural 
nerve is most superficial, in the groin at the inner side of the knee, at the 
upper and inner edge of the patella, and at various points on the inner 
side of the foot and leg. Muscular atrophy, which is probably a result of 
insufficient use of the limb, is sometimes a feature of the disease. When 
the pain is more severe at the knee-joint, we may find an enlargement of 
that articulation, and in some respects the condition may resemble arth- 
ritic inflammation ; but the cutaneous hyperesthesia is much greater than 
in the latter affection, while deep pressure does not produce the amount 
of pain it would in rheumatism. 

THE VISCERAL NEURALGIAS. 

The visceral neuralgias, especially those found to be connected with the 
uterus and its appendages, come more properly within the province of the 
gynaecologist than the neurologist ; SO a complete description would neces- 
sitate a consideration of the various pathological uterine slates which 
would be out of place in this book ; therefore our description must be ex- 
ceedingly brief. The importance of these latter forms of neuralgia can- 
doI be over-estimated. They are commonly of reflex origin, and depend 
very often upon some morbid condition of the uterus and ovaries them- 
selves. As Anstie remarks : "The amount and force of the peripheral 
influences which are brought to bear upon the central nervous system by 
the functions of the uterus and ovaries are greater than any that emanate 

from the diseases and functional disturbances of any other organ in the 
body." The menstrual period is that with which neuralgia of this kind 
i - . in nine-tenths of these cases, associated! It is essentially connected 
with irritability of the pelvic organs of the female, either when there is 
amenorrhoea and dysmenorrboea, or when the generatn e apparatus is over- 
excited by immoderate copulation or masturbation, or during tin' preg- 
nant Btate. When there i- :ui\ mechanical condition of narrowing or 
occlusion <>i the cervical canal, prolapsus uteri, intra-uterine growths, 
ulcers, or reflected irritation, neuralgia is not at all ;i rare accompaniment. 
I have found it \r\\- often as a symptom of general anaemia, with do ap- 
preciable uterine disease whatever. 



NEURALGIA. 431 



oYAJMA.x N EURALGIA. 



Ovarian neuralgia is symptomatized by excruciating pains radiating 
from these organs. It is not necessary that there should be derangement 
of menstruation, though such is generally the case. The pain may some- 
times be dull, but is more apt to be quite sharp. It is greatly increased 
by standing, or by fatigue following protracted use of the lower extremities. 
Among sewing-machine operators it is especially common, and many of my 
cases have been of this kind. It is generally connected with constipation 
or a sluggish condition of the circulation, sometimes leucorrhoea, hysteria, 
and always with a great deal of weariness and prostration. The suffering 
may be so intense and protracted as utterly to wear out the patient, and unlit 
her for any labor. It may be bilateral or unilateral. There are various 
other forms of neuralgia which depend upon reflected or local causes. 

URETHRAL NEURALGIA. 

This is not infrequently associated with stricture, gonorrhoea, or mas- 
turbation. It may be quite obstinate and of a paroxysmal character, and 
is much worse at night. I have found it very often where there has been 
a contracted meatus, in which case the pain ran up the penis. Vesical 
neuralgia, whieh may be connected with the presence of a stone, or which 
occurs as a result of long-standing cystitis, is symptomatized by pain at the 
neck of the bladder, while there may be some tenesmus. 

RENAL NEURALGIA, ETC. 

Renal neuralgia cannot be diagnosed with certainty, and probably the 
pain is in many eases due to the presence of calculi. Neuralgia of the 
testis is symptomatized by sharp pains of a temporary character ; and it is 
generally due to some distant source of irritation, such as the descent of a 
renal calculus, or the presence of a vesical calculus. I have seen eases whieh 
have followed excessive venery ; and Anstie reports a ease of epilepsy in 
which this form of neuralgia was undoubtedly the exciting cause. Self- 
abuse produced the "testicular neuralgia." which in turn precipitated the 
fits. With the pain there were vomiting and great prostration. Ascarides 
in the rectum may give rise to neuralgia of that gut. The pain is nearly 
always about the anus or just above the sphincter, and darts upwards. 
Cold and exposure are given as causes. The breasts are often the scat of 
a very painful neuralgia, which lias been called mastodynia. This is, in 
reality, a form of intercostal neuralgia, in which case the anterior and 
middle cutaneous branches of the intercostal of one or both sides are 
affected. It appears at puberty, or may accompany lactation when the 
nipples are cracked. In both these classes of cases there must be a 
lowered nervous condition; and. according to Anstie, masturbation pre- 
cedes the trouble in the youthful patient, while it is extremely probable 

that the strain upon the nervous system during pregnancy and lactation 



432 DISEASES OF THE PERIPHERAL NERVES. 

is often much greater than the badly-nourished patient can bear. I have 
met with the affection in perfectly healthy patients, and am convinced that 
the pain was purely neuralgic, and not dependent upon any inflammatory 
condition of the nipples. One of these patients was a prostitute, and had 
assiduously followed her trade, meanwhile losing sleep, and drinking to 
excess. 

Causes For the sake of conciseness, I may group the causes which 

are predisposing under the following several heads : — 

1. Hereditary. 

2. General diathetic (anemia, rheumatism, alcoholism, gout, syph- 

ilis). 

3. Psychical (intellectual, emotional). 

4. External (cold, pressure). 

5. Sexual. 
G. Reflex. 

Hereditary predisposition plays a most important part in the genesis of 
neuralgia, so important indeed that it is difficult to find cases of this dis- 
ease in whom there has not been some family history of previous nervous 
trouble. Insanity, paralysis, alcoholism, or convulsive disorders may be 
traced back; and of twenty-two cases collected by Anstie there were but 
five in which there had been no family neurotic history, and in some of 
these phthisis was found. This disease, according to Anstie and others, 
-.(in- to play quite an important part in the causation of neuralgia; 
and in one minutely detailed history given by him the appearance of 
tubercular meningitis and other neuro-phthisical diseases followed the 
engrafting of the pulmonary trouble upon the neurotic stock. Epilepsy 
enters extensively into the causation of many forms of neuralgia, especially 
epileptiform tic ; and not only may these other neuroses have appeared 
among the progenitors of the individual, but they actually exist with the 
neuralgia. 

Blandford 1 has called attention to a form of insanity which coexists 
with neuralgia, I lie pains subsiding during acute mental disturbance, and 
reappearing with its subsidence. Migraine is too common an accompa- 
niment of epilepsy to need more than a passing allusion. Chronic alco- 
holism is associated with a variety of neuralgic headaches and pains in 
the lower extremities, which are quite intense. Certain general diseases, 
which produce a cachectic condition, quite often give rise lo the disease, 
not only by actual mechanical disturbance of the nrr\ e-luiictious by effu- 
sion and periostea] disease, bul through the condition of mal-nutrition and 
enfeeblement of the nervous Bystem which originates in malaria, gout, 
rheumatism, and syphilis. The influence of malaria in the production 
of neuralgia is markedly Been in the South and Southwest, where the 
most violent attacks of neuralgia yield onlj to large doses of quinine and 
arsenic. The neuralgia is generally of the facial variety, bul it may take 

1 Insanity and its Treatment, p. 95. 



NEURALGIA 433 

the sciatic or any of the other forms. In many cases it is periodic, or 
occurs in connection with the chill and other features of the malarial at- 
tack. In most of the cases I have seen, it followed generally after a pro- 
tracted siege of "fever and ague," when there was extreme debility, 
" bone-ache," and enlarged spleen. 

Lumbo-abdominal neuralgia is far from being an uncommon malarial 
state, and is sometimes very apt to be mistaken for renal colic. Gout 
and rheumatism are not looked upon by Anstie as diseases which play a 
very important part in the general causation of neuralgia, from which 
opinion I am inclined to dissent. Putting entirely out of the question tie- 
local inflammation of the nerve-sheath, which is so often a cause of sciatica 
and other neuralgias, I am convinced that there are forms of the disease, 
aggravated by changes in temperature, coexisting with painful joints and 
extremely acid urine which disappear under alkaline treatment, and are 
not clearly examples of nerve-sheath inflammation. Gout, inducing very 
often a condition of general or cerebral anaemia, has been in my experience 
a very frequent cause of facial and other neuralgias. The condition of 
the liver, which occasions cerebral anamiia, melancholia, and over-loaded 
bowels, may also induce a neuralgia of a functional character. Not only 
in the tertiary form of syphilis, but, long before this, neuralgia may often 
be a troublesome symptom. I have had recently under my care an indi- 
vidual who had two years ago a primary sore, and has since had secondary 
symptoms. A chancroid, recently contracted, assumed a phagedenic 
character, and there were great debility and severe neuralgia, which suc- 
cumbed under specific treatment and nourishing diet. Profound anae- 
mia is very often found to be at the origin of neuralgia of various kinds. 
In women who have lost much blood during the menstrual flow, or in 
others who have become exsanguined from hemorrhoids, neuralgia is not 
to be looked upon as an unusual complication. 

The various constitutional diseases just alluded to may produce various 
forms of neuralgia, by inflammation of nerve-sheaths, with deposit, or. as in 
the case of syphilis, gummatous growths, or periostitis may make danger- 
ous pressure upon the nerve-trunk at some point where the latter is unable 
to withstand it without injury to itself. Syphilis, in rare instances, pro- 
duces irritation in the nerve-trunks themselves, giving rise to pain. This 
irritation, however, much more frequently produces motor paralysis than 
sensory disturbance. Mental overwork, shock, and a continued abnormal 
play of the emotions are likely to give rise to neuralgia, and for this reason 
literary men and hysterical women sutler very frequently. The headache 
of the overworked school child, compelled to overtax its brain, and de- 
pendent upon confinement in a hot room, is far too common. Want of amuse- 
ment, deep grief, and tie' pursuit of one narrow line of thought, are all 
influences which lower the integrity of the uervOUS system, and give rise 
to thi> as well as other ueuroses. Anstie's practical and judicious reasoning 
in regard to false religious training, and the dangers it may bring in the 
way of forcing the individual to become self-conscious, should BUggest to 

the physician and parent the necessity for avoiding everything in educa- 
te 



434 DISEASES OF THE PERIPHERAL NERVES. 

tion which promotes brooding, causes the individual to torture himself 
with doubts and self-accusation, and narrows the mind, thus depriving the 
nervous system of its normal exercise. Constant worry about business and 
any strain which demands an unusual expenditure of brain -force are causes 
of this kind. Exposure to cold and damp, particularly if there be wind, 
is a fruitful exciting cause of neuralgia, and persons who are exposed to 
draughts in railroad cars and public buildings very often owe their attack 
to Buch agencies. Pressure from various growths, cystic, cancerous, and 
gummatous deposits, not rarely causes distressing and intractable neu- 
ralgias ; but a syphilitic growth has been known to entirely surround a 
nerve-trunk without interfering materially with its functions. 1 Neuromata 
very frequently give rise to neuralgia. Such neuromata sometimes follow 
amputation or gross nerve-wounds, and the neuralgia is generally relieved 
by extirpation of the nerve-tumor. Various local troubles, of a peripheral 
or remote nature, produce neuralgia, and among these may be mentioned 
carious teeth, ascarides, and renal calculi. When carious teeth give rise 
to neuralgia, it is always very obstinate, and the cause may remain unsus- 
pected for a long time. 

Salter has observed cases of cervico-brachial neuralgia from bad teeth ; the 
variety most frequently met with however is facial neuralgia. This cause 
is ordinarily supposed to account very frequently for the head neuralgias, 
and many sound teeth are sacrificed by the individual, while there may be 
neuralgia of the two lower branches of the fifth from other causes. Over- 
use of the eves, and consequent fatigue of the muscles of accommodation, 
are supposed by some to have much to do with its production. Renal or 
urethral calculi, gonorrhoea, masturbation, and excessive venery, are all 
reflex causes of importance, and play a part in the production of lumbo- 
abdominal and other neuralgias. Uterine disease and overloaded bowels, 
or a fibrous tumor in tin; rectum, may by pressure often produce sciatica of 
a very obstinate variety, and aneurism more rarely makes pressure which 
gives rise to neuralgia. Digestive derangement and prolonged lactation 
may be mentioned as additional conditions which favor the production 
of neuralgia. As to age and sex, it is the opinion of most authors that 
neuralgia usually originates at the age of puberty, but the disease is QlOSl 
Common between the twentieth and fiftieth years. The following table. 

presented by Erb (Ziemssen, vol. xi.), possesses statistical value: — 













Yallrix. 


Eulenburgli. 


Erb. 


Total. 


Period of 


lift 


Up to 10 


j ea 


i, 2 


6 




— 


8 


(t 




(< 


to to 20 


u 


22 


1!) 




14 


55 


t( 




tt 


20 to 80 


(( 


68 


— 




40 


108 


it 




t< 


80 to 40 


" 


67 


88 




89 


L89 


u 




<i 


io to 50 


(I 


(it 


23 




2!) 


i 16 


(< 




» 


50 to 60 


" 


17 


l l 




1 1 


7.") 


n 




" 


60 to 70 


•• 


* 21 


(i 




9 


86 


(1 




1 1 


;u to go 


*« 


5 
296 


101 




1 
146 


6 
548 



Huebner, Ziemssen'fl Encyclopaedia, \ol. 



NEURALGIA. 435 

As to sex, Valleix collected 469 cases, 218 of whom were men ; Eulen- 
burgh 106, of whom 3<> were men ; Anstie 100, of whom 83 were men ; Erb 
14G, 84 being men. Of course there are varieties of neuralgia which arc 
confined more to certain ages and sexes. Migraine is more general among 
women, while sciatica is probably more often a disease of males. Anstie 
ami Hammond both consider facial neuralgia to he a disease of adult life. 
So far as climatic influences are concerned, neuralgia i- predisposed, and 
very often markedly affected by sudden changes in temperature. Dr. 
Weir Mitchell 1 has written a very valuable paper upon the Subject, which 
clearly shows the very decided influence of modifications of temperature 
and humidity. His article is based upon the personal note- of Captain 
Catlin of the U. S. Army, who suffered from stump neuralgia, and who 
intelligently and carefully noted the influences of atmospheric changes. 
Captain Catlin's conclusions were as follows : ''Neuralgic intensity does 
not seem to be proportioned to the amount of rain-fall. At the exterior 
of a storm disturbance the pain is usually less severe, and, indeed, at 
times I have been so far from the disturbed centre as to just percepti- 
bly feel it. A storm, reinforced by another at an angle of say '.'<»-. 
producing greater eccentricities in the curves, does not seem to produce 
a corresponding intensity or duration of the neuralgia." He adds : •• I 
am unable to state at what point within the disturbed area the pain would 
be strongest. The abruptness of the barometric fall does not seem to have 
much to do with the causing of pain, nor is the length of attack dependent 
as it seems on the length of the storm." 

Pathology Neuralgia is always the result of lowered functional 

activity dependent upon the trophic disturbance of a sensory nerve. This 
is probably attended by some change in the posterior nerve-roots, which is 
not necessarily inflammatory. The morbid anatomy of neuralgia has 
thrown but little light upon the pathology of the disease, so our conclu- 
sions must be based upon purely theoretical grounds. Erb, in speaking of 
the nutritive disturbances, says: " In regard to the ordinary seat of this 
trophic disturbance, nothing accurate 1 is known : but it is probable that 
the seat varies, and this much appears certain, that for the most part a 
definite group of fibres (or their central terminations) as they are combined 
to form a nerve-trunk or branch, is affected. At what place in the length 
of the nerve this is present it is difficult to say, and perhaps may be at any 
length. The peripheric fibrils maybe affected at various points and vari- 
ous lengths of their course, or the posterior roots and their prolongation 
in the spinal cord may be the seat of the neuralgic trophic disturbance : 
or. Lastly, the central fibrils running in the spinal cord or brain may be 
affected up to the terminal central apparatus. The investigations that 
have hitherto been made have acquainted US with many important tact-, 
but have furnished no very satisfactory conclusion." 

The clinical features of neuralgia enable us to understand many of the 
phenomena which ordinarily characterise the disease, and we are allowed 
to assume that lowered nutrition from general or local disease, reflected 



1 Am. Joum. of Med. Science, April. 1>77. p. 






436 DISEASES OF THE PERIPHERAL NERVES. 

irritations, and mechanical pressure enter into its production. Instead of 
a normal stimulus being conveyed by a healthy nerve to the centre, the 
nerve may be functionally impaired for conduction, or the centre so altered 
in its receptive faculty that the sensation period is grossly exaggerated. 
The receptive faculty of the peripheral fibrils may be so exaggerated that 
ordinary stimuli are received and transmitted in a painful form. Why 
the disease should be paroxysmal we do not know. 

Morbid Anatomy. — It is by no means a matter of necessity that a 
nerve which has been the seat of neuralgia is found to be changed in struc- 
ture. Accidental atrophy, hyperemia, and indications of neuritis are 
sometimes exhibited. Thickening of the nerve and sheath deposits in its 
neighborhood, or enlarged vessels, tumors, aneurisms, and the like, are 
occasionally met with. On the other hand, nerves have been removed 
which have been perfectly healthy. In old cases of neuralgia the posterior 
nerve-roots are nearly always atrophied. 

Diagnosis. — We may briefly sketch the character of the symptoms. 
Tin' pain of neuralgia is paroxysmal or dull, with paroxysmal recurrences ; 
rarely tenderness upon pressure, except at certain situations. Neuralgic 
pain is rarely constant, while that of neuritis is quite so. The pain of 
neuralgia follows the course of some nerve, is quite acute, and has a lanci- 
nating, terebrating, or shooting character. It is also connected with vaso- 
motor changes in the skin. The existence of a cause must be considered, 
and the fact whether " hereditary predisposition" is present or not. Facial 
neuralgia is very rarely mistaken, and should not be when the fact is taken 
into consideration that the pain is generally referred to one of the branches 
of the fifth nerve. Pleurodynia is sometimes confounded with pleurisy, 
hut the absence of physical signs should be sufficient to make the diag- 
nosis (dear. Lumbo-abdominal neuralgia is very frequently confused with 
various painful affections of the viscera. Among these may be mentioned 
renal colic, the pain of nephritis, and intestinal colic. Sciatica, from its 
unilateral character, is not likely to he mistaken for any oilier affection. 
The important indication in diagnosis is to determine the variety of neu- 
ralgia, whether syphilitic or malarial, whether due to compression or con- 
nected witb neuritis, or whether due to enlargement of and pressure from 
any of the abdominal organs. 

The following are to he remembered and consulted for guidance in 
making a diagnosis — 

A. Cause: history of previous attacks. 

II. Character of pain; paroxysmal, inconstant. 

('. Aggravation by debility or fatigue. 

I). The presence of " painful points." 

E. It- distribution (following course of nerves). 

F. Rarely aggravated by pressure, except at limited points, which 

correspond to superficial course of the nerve. 
( i. It.- general unilateral character. 

Prognosis Neuralgia of all kinds i-- more curable in early life than 

in advanced age, and it nun he assumed that, when ii hue lasted for many 



NEURALGIA. 437 

years, and is severe in character, it will be most intractable; this is 
especially the case in the disorder known as tic epileptiform, which may 
be said to be nearly always incurable. In these troublesome cases even 
removal of the nerve affords but temporary relief. When atrophy of mus- 
cles has taken place the chance of cure is very remote, and if the can-' 
be a deep one, such as pressure for instance, nothing can generally be done. 
There is a bright side of the picture however. Functional neuralgias, or 
those of the syphilitic variety, readily succumb to proper treatment; and 
sometimes general nourishment and the removal of the exciting cause will 
speedily restore the patient to his normal condition. 

Those neuralgias which develop later in life are attended by structural 
decay, arterial degeneration, and are very hopeless. As to the curability 
of the varieties of neuralgia, that of the fifth nerve is most persistent, and 
intercostal neuralgia perhaps least so, whilst sciatica holds a place midway 
between the two. As an example of a severe and intractable continued 
neuralgia, connected probably with angina pectoris, I may present the 
case of 

Lucy L. S., sixty-five ; U. S. ; married. Previous History When a 

young child she fell, striking her right eye on a chair-post. For several 
days it was supposed she had lost her sight, but this was found not to be 
the case. After this she had pain in the left side and shortness of breath. 
whenever she attempted to run. At twenty-one, she had an attack of 
cerebral hemorrhage, which affected the right side, but there was >"> 
aphasia. This was accompanied by anaesthesia, which has never entirely 
disappeared. About this time there were diplopia and ptosis — the latter 
symptom being now present. Supposed pulmonary trouble at twenty-four. 
Married at twenty-five. 

" Before birth of my second child, I was subject to dizziness, and neu- 
ralgia of the fifth nerve, which was most intense in the morning. 

When nearly twenty-eight, and my second child was a few days old, 
I ' commenced to see dark spots, sometimes like black specks, again 
like circles with spotted centres.' When this child was three or four weeks 
old, sharp pain commenced in right side of the head. After sleep, the 
pain would subside, and vision would improve. At intervals of from three 
to four weeks, or when tired, these blind attacks would return, accom- 
panied either by sharp pain or dizziness in head. For the next eight years 
I was comparatively well, having occasional 'blind turns' when tired. 
At these times my forehead would feel as if strings were being pulled in 
Opposite directions, and there was much twitching in the right eye. All 
these years there was some pain about the heart, witli palpitation. 

At forty-one the change of life commenced, and 1 Buffered several years 
most intensely. 

All iliese years there was some difficulty around the heart. Palpitation 
and some pain at intervals. 

For the past three years pain has been about equally divided between 
head and heart; sometimes commencing in one and sometimes in the 
other. Some six months ago pain seemed to be settling around heart 

particularly. Would come on with a chill and creeping sensation up the 
spine, and would begin with a whirling in left side. A palpitation of the 
heart would come on if excited or tired. Outward applications and medi- 
cine taken seemed to drive pain across from left Bide to right Bhoulder. 



438 DISEASES OF THE PERIPHERAL NERVES. 

Would go into right side of the head; follow down right arm into hand. 
Also into left arm and hand. Hands have been much drawn up, and 
Streaked with red. When pain was in face, it would be spotted red and 
white on right side only. When severest in side and heart, eyes became 
set in head ; face livid, and blood would settle under nails. After endur- 
ing pain, tremble much in limbs." 

I saw the patient during the past spring, and found her to be a rather 
spare, badly-nourished woman, and she presented the following symp- 
toms : — 

Objective The right eye was examined and found to be sightless ; 

the retina was the seat of an old neurosis, with atrophy of the disk. There 
was slightly developed ptosis of this eye, and some keratitis, corneal opacity, 
and ulceration, so that she was obliged to wear a shade. The right side 
of the face was slightly anaesthetic and analgesic. iEsthesiometer contact, 
and extremes of temperature were not readily perceived. The same was 
the case in the skin of the right arm, forearm, and hand, but more decidedly 
the latter. The hand presented the appearances to be hereafter described 
article upon Neuritis), and was markedly anaesthetic, and the skin 
showed evidence of impaired nutrition. The right lower extremity was in 
a much better condition. There was very slight loss of motor power on 
the right side. 

Subjective She now has attacks of severe facial and cervico-brachial 

neuralgia which come on every two or three weeks, and has had one. 
within a day or two ; there is still some tenderness left at various parts of 
the t'aee and right upper extremity. The pain seems most intense in the 
upper branches of the fifth, and has never affected the inferior maxillary 
to a decided degree. The arm-pain and head-pain are simultaneous in 
their onset, and arc preceded by the ordinary prodromata of an attack of 
this kind. They are always paroxysmal, and seem to reach a climax and 
then subside. During the attack the eye is seemingly "forced forwards." 
After the attack she is entirely free from pain. With the seizure there is 
cardiac trouble, and respiratory trouble which suggests some impairment of 
the pneumogastric. 

She never has convulsions or vomiting, and there is no deep localized 
pain at any point in the superior aspect of the cranium ; but all pain at this 
point is superficial, and would evidently come under the head of hyper- 
esthesia. 

In this case there is a decided hereditary history of nervous disease. 

Treatment. — In nine-tenths of the (rases of neuralgia the manage- 
ment of the disease Bhould be undertaken with the assumption that, the 

pain is due to Lowered functional activity and depressed tone; and while 
local treatment is no1 to be forgotten, it is absolutely imperative that the 

patient should be supported, and that drugs which improve the nutrition 

of the nervous system should be selected. It is well to minutely inquire 
into thr existence of other disease, and reference to what I have already 
said about etiology will furnish^the reader with Buch hints as may be neces- 
sary. Should menstrua] [Regularities, gastric derangement, or constitu- 
tional diseases be found, it is well, I may Bay absolutely necessary, that 

these should be corrected before anv local treatment is to be undertaken. 



NEURALGIA. 439 

Neuralgic pain is very variable; and although, for my present purpose, 1 
shall make use of two expressions to denote its character, there is much 
that must necessarily remain unsaid in regard to its variation and pecu- 
liarities. 

I shall describe the pain of neuralgia as coarse i\m\jine, two divisions 
which, though somewhat arbitrary, are useful when we speak of treatnx nt. 
Fine neuralgic pains may be said to be those of a sharp paroxysmal cha- 
racter, leaving behind no points of tenderness, and entirely unconnected 
with any suspicion of neuritis. Coarse neuralgic pains may be said to in- 
clude the brusque pains, which bring local tenderness and soreness, and 
are aggravated by movement. The former are those which sometimes 
occur during migraine and functional neuralgia of the lighter kinds ; while 
the coarse pains may be often the result of sciatica, in which the move- 
ment of the limb in walking or the pressure of the chair is sufficient to 
give rise to them. In one form of the latter our treatment should be quite 
negative, and of a character which necessitates the use of counter-irritant-, 
such as blisters and the actual cautery ; while the former is best treated 
by remedies which either increase the blood-supply of the nervous centres 
and improve their tone, or allay reflex irritability. The treatment of 
facial neuralgia or migraine should be the following : The use of diffusible 
stimulants; muriate of ammonia (FF. 93, 94) being, perhaps, one of the 
best. It should be given in large doses quite frequently, beginning with 
from twenty grains to a drachm, which should be repeated every hour 
during the attack. Coffee and tea, or their alkaloids, are often serviceable ; 
or we may prescribe guarana (F. 94), which is a very valuable remedy, 
in doses of half a drachm to a drachm every hour. I have never wit- 
nessed any bad results from the use of this drug, even when quite large 
doses were taken. The powder is the best preparation. Tr. belladonna 
(FF. 44, 70, 76), given in small repeated doses, does much good if the 
disease be of a reflex character. The drugs recommended for this variety 
of neuralgia are quite as numerous as most of them are useless. The alka- 
loids daturine (F. 92), and conia (F. 91), have been used in obstinate cases 
of tic epileptiform with varying degrees of success, but great care should 
be taken. I have often broken up an attack of ordinary facial neuralgia 
with a cup of strong hot tea, or even a cup of hot water ; and now have a 
patient who has been in the habit of taking an emetic, which has almost 
immediately given her relief. Cannabis indica, either in the form of the 
extract or tincture, is of service when guarana fails. Its use should he 
continued for several months. If the neuralgia be malarial, a "stiff" do-.' 
(say twenty grains) of quinine rarely fails to abate the paroxysm. As 
local applications, various stimulating liniments are used, the besl 1 
know being the compound soap-liniment ; or a mixture of chloroform, 
tr. aconite and camphor (F. 03), an ointment of veratria (F. 65), or of 
chloral and camphor (F. (17), sometimes afford relief, and 1 have wit- 
nessed the good effects of a tincture made of the berries of the belladonna 
(F. 9-")). The blister or actual cautery may be brought into requisition if 



440 



DISEASES OF THE PERIPHERAL NERVES. 
Fiir. 49. 




(tun 'H limits 



/)f//> I Won id I. 



NEURALGIA. 441 

Superficial Points and Cutaneous Areas of Xerve Distribution.— 1, 2, S, 4. Points for 
galvanization of fifth nerve. 5. Brachial plexus. 6. Musculocutaneous. 7. Median. 
Ulnar. 11, 12. Crural. 1.5. Peroneal. 14. Tibial. 1.0. Occipital. 16. Radial. 17, 18. Sciatic 
19. Popliteal. 20. Peroneal, ac. Acromial. Cir. Circumflex. Int. h. Internal humeral Ext.e. 
Externa] cutaneous. Int. e. Internal cutaneous, c.p. Cutaueous palrnaris. y. u. Palmaria 
ulnaris. rn. Median. Had. Radial. u. Ulnar. Mas. Sp. Musculo-spiral. Ilio-Hy. Ilio- 
hypogastric. /. I. Ilio-ingninal. Lot. Cut. Lateral cutaneous. E S. External spermatic. 
Lum. I. Lumbo-inguinal. Pos. C. Posterior cutaneous, ob. Obturator, nam. 'p Communicating 
peroneal. In. sa. Internal saphena. Sup. p. Superficial peroneal, eprn. Posterior median 
cutaneous. Cpp. Cutaneous plantaris proprius. Pll. Plantaris lateralis. 

painful points are found, and I have been in the habit of using the ether 
spray just in front of the ear in migraine. In tic douloureux I am convinced 
that there is no better remedy than gelseminum given in large doses, begin- 
ning with ttl viij to TTLXvof the tincture orfl. extract (F. 50). My frit-mis 
Drs. Kinnicutt and Clymer have both mentioned to me the detail- of cases 
where by accident the patient had taken toxic doses of this drug. In one 
of these the disease entirely disappeared after the alarming effects of the 
remedy had passed away. Croton-chloral (F. 47), which has lately been 
recommended for facial neuralgia, I am convinced has been overpraised: 
I have given it a fair trial, and have rarely found it of any use. If it is 
employed twice a day in twenty-grain doses, it will do more good than 
in the small repeated doses. The removal of carious teeth is often 
followed by speedy disappearance of the disease. Should the face become 
tender, as it not uncommonly does, the patient should be directed to keep 
it carefully protected by cotton-batting ; and if painful points remain 
in the roof of the mouth or gums, they may be lightly touched with the 
hot glass rod or iron. The treatment of cervico-brachial, cervico-occipital, 
and other neuralgias of the trunk may be managed after very much the 
same plan. In each particular case of course the treatment varies. If 
there be a diathetic condition, such as syphilis, mercurial inunctions, 
baths, and speciiic treatment (FF. 17, 18, 19,20, 45) are to be made use of 
in conjunction with local applications. The advantage of large doses of 
quinine in cachectic headaches, as well as in intercostal or lumbo-abdo- 
minal neuralgia, especially if there be an herpetic eruption, I have men- 
tioned. In these forms, as well as in ovarian neuralgia, the use of local 
cold, such as may be obtained by ice-bags, or the application of blisters, 
is very efficacious. The actual cautery, employed to make sweeping 
strokes along the course of the nerve, or down the back on either side of 
the spinous processes, and in paths which run at right angles to the lon- 
gitudinal "stripes," may be brought into requisition, and applied twice or 
thrice weekly. Sciatica sometimes demands most obstinate treatment. 
The actual cautery, and even nerve-stretching, may be necessary ; but in 
the majority of cases galvanization of the nerve does great good, and 
should be faithfully tried before anything else is done. 

Electricity affords very decided relief in this disease; and galvanism, 
when judiciously employed, rarely fails to modify, if not cure neuralgia. 
In facial neuralgia it should be applied to the nen e by -mall sponge~co\ ered 

electrodes, one pole being placed just behind the condyle of the jaw. and 
the other held lor a. few minutes o\ er the supra-orbital and infra-orbital 



442 DISEASES OF THE PERIPHERAL NERVES. 

foramina, or over the symphysis of the lower jaw. The current should be 
the direct (from positive to negative, the negative pole being peripheral). 
The admirable plates of Beard and Rockwell, and the suggestions of 
Ziemssen, will enable the reader to comprehend the situation of the points 
corresponding to the superficial course of the various nerve-trunks, so that 
they shall be brought most readily under the influence of the current. 
Faradism of the intercostal nerves, and of regions of distribution of 
terminal filaments of other nerves in various neuralgias, is of great service, 
and rarely fails to afford relief in sciatica. 1 have seen pleurodynia dis- 
appear in ten minutes after the use of the faradic current. The following 
case shows the value of electrical treatment. 

Mr. S. After constant exposure during the war, the patient con- 
tracted a low typhoid fever, which left him weak and emaciated for a 
long time. Since 1868 he has had twinges of pain down the back part of 
the leg, which have left him in a perpetual state of misery, with only oc- 
casional intervals of several months when he is absolutely free from pain. 
In winter his trouble is worse, and any exposure will immediately pro- 
duce a severe attack of neuralgic pain. Any indiscretion in his diet will 
also be followed by the sciatica. He had gone through the usual siege of 
medication, including morphine, hypodermics, and stimulating lotions. 
He came to me in July, 1871, when I made applications of galvanism to 
the nerve by the conical sponge-electrode, the sponge being held firmly 
over the obturator foramen. At the first visit his pain was excessive, but 
after fifteen minutes' application he left, feeling a sense of relief which he 
had not known for months. Two months and a half of this treatment 
were sufficient to dispel the pain, which did not recur. Four months 
afterwards, he made a visit, when he stated that he had not had any re- 
turn. 

In the treatment of neuralgic attacks the hypodermic syringe has 
played a very important part. I have no doubt that it has been abused, 
and I have become painfully aware that individuals have thus acquired 
the habit of opium and morphine self-administration. For the radical cure 
of certain varieties of neuralgia, the hypodermic syringe has no equal. 
My friend, Dr. T. M. B. Cross, was the first, I believe, to use deep in- 
jections of morphine in sciatica. He has recommended that the point of 
tin- syringe needle be carried down to the sheath of the nerve, and the 

contents of the barrel gradually expelled. Strange to say, very few acci- 
dents have followed its use, although the wounding of an artery is not an 
impossibility. Chloroform 1ms been used hypodermically. by Bartholow, 1 
ami with great success, ami though 1 have produced abscesses in this way, 

I ;nn inclined now to acknowledge its value as a therapeutic measure. 

Morphine and atropine (F. 59), daturine (F. 92), ergotine (F. 60), and 
other alkaloids are constantly used, and sometimes afford relief, which is 
generally temporary, hut occasionally permanent. The genera] treatment 
is, however, all important, and* iron, Btrychnine, arsenic, cod-liver oil, 
.•in. I phosphorus ( FF. 2 I, 25J 26, 8, 9, L0, 82) rank high as valuable 

1 Mat. Medics ami Therapeutics, p. 821, et sop 



NEURALGIA. 443 

remedies. I have spoken of quinine. I may add that when given con- 
tinuously, either in combination or alone, it cannot fail to do good. Phos- 
phorus always does good, except in forms of neuralgia which are not 
directly dependent upon depraved nutrition, and are due to cold or in- 
tended by inflammatory conditions. Thompson's solution (F. 85) is the 
best preparation. Salt air, with alternations of mountain air, nourishing 
diet, which should include a largo proportion of Don-nitrogenous food, 
attention to the daily habits, the removal of fecal accumulations, and the 
re-establishment of menstrual regularity are of the greatest importance, 
and should be accomplished if possible. 









444 DISEASES OF THE PERIPHERAL NERVES, 



CHAPTEE XVI. 

DISEASES OF THE PERIPHERAL NERVES (Continued). 

NEURITIS. 

Symptoms — Inflammation of a nerve is expressed chiefly by sore- 
ness and tenderness, and not by the darting or paroxysmal pain whicli 
constitutes neuralgia. When confined to the nerve-trunk various depraved 
conditions of sensibility, motility, and trophism may follow, which are 
expressed by cutaneous and muscular changes; and the course of the nerve 
can usually be marked with great exactness, for pressure produces great 
pain. The skin may be red or the seat of bullous or pemphigous erup- 
tions. Of course very much depends upon the character and importance of 
the nerve affected. Some of the nerves of sensibility, such as the fifth, when 
subject to neuritis, are followed by symptoms different from those which 
occur when the seventh or one of the mixed nerves is affected. Peripheral 
inflammation of the external portion of the seventh is often the cause of 
facial paralysis, and neuritis of the fifth may occasion disorders of sensi- 
bility as well as ulceration of the cornea and other trophic phenomena. 
With neuritis there is not infrequently loss of tactile sensibility and 
sense of appreciation of temperature, though in the beginning the skin is 
hyperaesthetic, and the pain is aggravated by contact with cold or hot sub- 
M;nircs. Erb speaks of acute and chronic neuritis, the former depending 
upon traumatism, sloughing, or eancer„and beginning with a chill, fol- 
lowed by fever, headache, and sleeplessness. The pain commences in the 
affected member, and extends, until finally chronic neuritis is progressive, 
the inflammation spreading, and involving new nerves. This extension 
may be recognized by the fresh appearance of pain in new localities; by 
painful points (Valleix's) at new regions, by difference in the form of pain, 
and by variations attending pressure; the whole limb is affected. This 
author, as well as Mitchell, considers that it is most intense at night, and 

that it is augmented by movement. Mitchell has observed intense hys- 
terical excitement, and even delirium. A red line usually marks the 
(•(.in--. • of tie- affected nerve, and there may be patches of herpes or pem- 
phigus, or the skin may be (edematous. In one ease, observed at the Epi- 
leptic Hospital, the patient, a negress, presented symptoms of neuritis of 
the anterior tibial nerve, and the skin of the fore part of the right leg Wafl 

tense, Bhiny, and exquisitely sensitive. A marked rigor ushered in its 
development, and there were subsequently nausea and vomiting. Her 

pulse Was feeble and rapid, and she could not. sleep, and entirely lost her 

appetite. There was no inflammation whatever of the skin or muscular 

tissue, and the RCUtS pain Subsided in a few weeks, but there remained a 






NEURITIS. 445 

condition of great tenderness. Hot and cold applications increased the 
pain. 

Paralysis may follow, and is by no means uncommon. The patienl 
generally recovers in a month or so, and sometimes in a shorter time, but 
the neural condition never entirely disappears. Jn the chronic form the 
onset may be gradual or spontaneous, or follow an acute attack. J have 
sufficiently sketched the symptoms, and will only add that muscular cramps, 
tremor, or permanent contractures sometimes form very distressing sequela?, 
and with these there is paralysis. Anaesthesia or hyperaesthesia is con- 
nected with neuritis, the former being of late; appearance. Erb call- 
attention to the comparative immunity of the motor nerves, as paralysis 
does not follow until after a long train of sensory disturbances, but reflex 
disturbances are not uncommon. These may consist in remote nerve pain, 
cramps of distal muscles, or hysterical attacks. The electric excitability 
in the early stages is exaggerated later, or it is lost," and if there be para- 
lysis there is very marked muscular atrophy as a consequence, and electric 
contractility disappears altogether. By far the most interesting changes 
are those of a trophic character. Weir Mitchell has presented the most 
complete description of these structural alterations. The finger-nails lose 
their normal character, and become horny and curved, and the skin 
becomes rough and is sometimes exfoliated. 

As additional evidences of this defective nutrition, " hang nails," crack- 
ing of the skin and other slight changes from its healthy condition are 
striking indications. The illustration (Fig. 50) which 1 produce is from 

Fio-. 50. 




Trophic Change of the 5 da. 
the photograph of a patient whose hand had been anaesthetic for some 

veins. The skin is hard, the palmar furrows are Bharp and exaggerated, 

and the bases are red or purple, somewhat resembling the same appear- 



44G DISEASES OF THE PERIPHERAL NERVES. 

ance in the cutaneous flexure of the knee, elbow, or other articulating 
parrs in certain forms of chronic eczema. 

Causes The acute variety is dependent upon injuries of various 

kinds. I have seen one case which followed a carbuncle situated upon the 
inner Burface of the forearm, and Mitchell reports several cases following 
gunshot wounds. Flying splinters, fractures, and blows are various trau- 
matic causes, while the extension of cancerous disease or sloughing may 
produce a neuritis. Cold, rheumatism, and syphilis enter into the etiology 
of the affection, and Mitchell has produced a neuritis by the local applica- 
tion of ice. In one case of facial spasm, for which I used the ether spray, 
1 was disagreeably surprised to find a remaining neuritis of the portio 
dura, which lasted for some time. 

Bean has directed attention to forms of neuritis of the intercostal nerves 
which undoubtedly arose from pleurisy and plenro-pneumonia. Typhoid 
fever, diphtheria, and other diseases of a febrile nature are not infre- 
quently attended by neuritis, and in one case of typhus, reported by Bern- 
hardt, a neuritis involved the musculo-spinal nerve. 

Morbid Anatomy and Pathology Inflammation of a nerve- 
trunk produces very decided changes in its appearance. It becomes 
swollen, is of a pinkish hue, and there is often an exudation which is found 
between the fasiculi ; this may be also of a reddish color. The micro- 
scopical appearance of the nerve is still more characteristic. The nerve- 
fibres undergo marked changes ; the axis, cylinder, and the medullary con- 
tents are disintegrated ; the neurilemma, may be distended by serous exu- 
dation, and the bloodvessels are enlarged and in places ruptured, so that 
blood-elements may be found scattered in different regions. In later stages 
there may be atrophy or fatty degeneration. In chronic neuritis these 
appearances of advanced degenerative changes are found to consist in 
proliferation of connective tissues, and .this takes place as an interstitial 
formation. Degeneration of the minute nerve-elements, deposition of oil- 
globules, and Sclerosed patches are found in old cases. 

If the inflammatory action be very severe, the nerve will be found to be 
Completely destroyed by sloughing. The nerve may be found the seal of 
enlargements, which are to be seen at different localities in its course, 

and at each of these points there may be a ditlerent kind of change. In- 
flammation of a nerve-trunk, as J have said, is lirst attended by sensory 
change.-, which may be local, or in other parts; as die result of reflected 
irritability; afterwards trophic changes may result either from the pro- 
duction of some pressure upon other parts, or through loss of function of 

the nerve it -elf. 

Diagnosis. — The limitation of the pain, its aggravation by pressure, 
it- constancy, and it< character, enable us to generally distinguish it from 
neuralgia. In chronic neuritis it is not so easy to make such a diagnosis. 
The painful points found in neuralgia maybe mistaken for the sensitive 
Bpots in neuritis. I have Been very i«'\\ cases in which the pain of neuritis 
was not constant^ and this is not the case in neuralgia, which is essentially 
a paroxysmal disease. Painful swelling of the nerve and paralysis of mus- 



NEURITIS. 447 

cles supplied are also evidences of neuritis, -which will aid us in discover- 
ing the nature of the affection. 

Muscular rheumatism has been spoken of by Erb as a condition with 
which the disease under consideration may be confounded. I consider 
such a distinction to be a refinement of diagnosis which cannot be made. 
* ; Muscular rheumatism" is, after all. a low grade of diffused neuritis, 
and the most we can do is to discover the cause of such pain. 

Erysipelas, thrombosis, and embolism are distinguished by the evidences 
of subcutaneous swelling, (edema, etc., and by their somewhat diffuse 
character. 

The presence of a traumatism should be taken into account, and its nature 
investigated. 

Prognosis Structural alteration of a nerve must follow an inflam- 
mation such as has been described, and unless the symptoms have been 
very slight there is a tendency to continuance, so that an attack of acute 
neuritis assumes a chronic character. If the inflammation has advanced 
centrally, so that a new plexus is involved, the prognosis is very bad. 
Treatment has much to do in some cases with prognosis. 

Treatment To Mitchell we are indebted for excellent directions 

for the management of neuritis. He tried elevations of the leg or arm, 
while bladders of ice were applied to every part of the limb, and Jf gr. 
hypodermic doses of atropia. with ^ gr. doses of sulph. of morphia, were 
injected every four hours, or oftener. He has used leeches, so that con- 
siderable local abstraction of blood should take place. Perfect quiet is 
highly important, and he recommends splints for the purpose. I have 
used the plaster bandage in a way to leave the course of the painful nerve 
exposed. The actual cautery is invaluable, especially when the disease is 
chronic, and it should be freely applied along the painful tract. Faradi- 
zation does good, but I have no faith in the galvanic current, which only 
increases the pain. Hypodermics, either of morphia, atropia, or ergotine 
(FF. 59, 60, Gl), in the neighborhood of the painful point, may be continued 
for some time, with the effect of diminishing the pain and the violence of 
the inflammation. Large doses of iodide of potassium are of especial 
service : and I have lately recommended inunctions of mercurial ointment 
with excellent results. This latter treatment is that which we are to 
employ when syphilis is suspected ; and the good effects are sometimes Been 
in a few days. Asa dernier ressort nerve-section may be resorted to; but 
if the neuritis has involved a nerve-plexus it does no good. It is only 
when a peripheral nerve is affected that it removes the disease. 

In nerve-stretching — a new and extremely valuable surgical procedure 
— we possess a means which, though not extensively tested as yet. 
promises to be of great service. The nerve is exposed, and forcibly pulled, 
so that the limb shall be raised. In one instance the portion ot' the lower 
extremity, including the leg and foot, was drawn up by the sciatic, which 
had been bared in its course down the thigh. 



448 



DISEASES OF THE PERIPHERAL NERVES. 



ANAESTHESIA. 



Symptoms An impairment or loss of cutaneous or muscular sensi- 
bility, either localized or extensive, may be the result of central disease, or 
it may be of a strictly peripheral nature. It is of the latter that I now 
propose to speak. 

The anaesthesia may imply loss of the sense of appreciation of extremes 
<>t' temperature, contact, or painful impressions. 

In the optic nerve, amaurosis is a result, and with this there is commonly 
anaesthesia of the ciliary nerve, so that the influence of light possesses no 
irritant effect. Deafness follows auditory anaesthesia, and loss of taste 
anaesthesia of the lingual nerve. 

Anaesthesia and analgesia may exist alone or in complication, and we are 
constantly reminded of this state in cases where operations are performed 
on insensible parts, the individual only feeling the power of traction or the 
contact of the surgical instrument. This is often observed in some of the 
uterine operations ; and Dieffenbacli 1 alludes to the anaesthetic condition 
produced by some of the agents employed, which only blunt sensibility, 
while the sense of contact still is preserved. I have myself witnessed this 
phenomenon in patients in whom local anaesthesia had been used. 

In cutaneous anaesthesia a warm or cold body is not appreciated as 
such, but the individual can sometimes tell its shape, or feel the pressure 
made A lump of ice is said to be irregular. The button of the heated 
cautery iron, if pressed against the skin, produces no discomfort, but only 
a sense of weight. This loss of tactile sensibility is generally abolished, 
however, or greatly diminished. The patient will either not feel the 
points of the a sthesiometer at all, or, if he does, will be unable to tell how 
widely they arc separated. 

The local temperature and vascular Supply are altered in many cases, so 
that tin- warmth of the spot which has become anaesthetic is a degree or 
two below that of the sound parts adjacent. The vascular alterations are 
attended by bloodlessness and whiteness of the affected region. This 
diminished blood-Supply of Course invites pathological alterations of nutri- 
tion, for. when subjected to influences of temperature or injury which other 
normal districts would bear without damage, the anaesthetic skin becomes 
rapidly altered as far as its integrity is concerned. Romberg 8 alludes to 
the occurrence of blisters and ulcerations which were readily caused during 
cold weather; and I have repeatedly seen the effects of injurious pressure, 
of surgical operations, and of the application of irritants. In one patient 
brought t<> UK' I was surprised to find an extensive ulceration of the >kin 
of the forearm, which had resulted from the use of a, stimulating liniment 

which the patient hail used with the idea of improving an anaesthetic stale 

dependent upon rheumatism. 



1 Du /Ethergegen den Schmerz, 1847, p. 61. 

1 Manual of the Nervous Diseases of Man, p. 202. 



ANESTHESIA. 449 

Ancesthesia of the Fifth Pair. — Thia form of anaesthesia ie commonly 
of peripheral origin, and of thirty-five cases collected by Ortel-Ebrard 1 it 
resulted but nine times from intracranial tumors. It is of spontaneous 
origin usually; and the upper branch is most profoundly affected, so that 

the loss of sensibility is limited to the brow and region about the eye, by 
anaesthesia of the cornea, and consequent nutritive changes in thai part of 
the optical apparatus. A ease of this kind was reported by Dr. 11. I). 
Noyes, 2 of New York, in which there was very decided sloughing of the 
cornea. The phenomena following anaesthesia of this nerve may be thus 
tabulated : — 

{ Anaesthesia of upper eyelid 
Involvement of ophthalmic branch. ■) and forehead. Irritating 

( substances are not felt. 
f Anaesthesia of middle por- 
Involvement of superior maxillary branch. J tion of face. Insensibility 

( of gums of upper jaw. 
Anaesthesia of skin of lower 
portion of face; increased 
flow of saliva ; mastication 
difficult ; gums of lower 
I jaw insensible. 



Involvement of inferior maxillary branch. 



The patient sometimes finds that the edge of the tumbler or vessel from 
which he drinks occasionally feels as if it were broken. Several of these 
cases are reported by Bell. 3 In one of my cases the patient could not 
spit in a straight line, while the secretion of saliva was quite abundant. 
This same patient complained that his gums were insensitive. These 
peculiar buccal and labial symptoms are generally early and prominent 
expression-. Sense of smell and sensibility of the nostrils and tongue are 
lost when other branches are affected. 

"When the radial nerve is the seat of the peripheral trouble, it will be 
found that the back of the hand retains its sensibility. The lower ex- 
tremities may be affected when the condition is the result of pressure 
made upon the sciatic, and in the case of several skin-diseases the loss of 
sensibility may be general. Leprosy, syphilitic alopecia, and other skin- 
diseases may all be attended by loss of cutaneous sensation, which is the 
result of local dermal alteration of function. Bulkier* has very ably 
considered this subject. 

Causes. — Cutaneous anaesthesia may be due to pressure made upon 
a nerve-trunk in its course, or to the compression of peripheral ana- of 
greater or less extent, or to local impairment of function by exposure to 



1 Paralysie du Trijemineau, These Paris, 1867. 

2 N. V. Medical Journal, L871. 

1 The Nervous System, etc., 3d ed., p. SS8, ei seq. 

4 The Relations of the Nervous System to Diseases oi' the Skin. Archiv, ot* 
Elect, and Neurology, 1874-5. 
29 






450 DISEASES OF THE PERIPHERAL NERVES. 

cold, to certain chemicals, or to like agents ; while general diseases, such 
as syphilis or rheumatism, by local disease and infiltration, greatly alter 
the function of cutaneous nerve-filaments. Intense cold, liniments which 
contain aconite, or long immersion of the bands in fluid of any kind, will 
result in a loss of sensibility. One of my patients was a dyer, whose hands 
were kept in warm dye-liquids for many hours; and some of the French 
writers give examples of the disease among washerwomen. Alkaline 
fluids are more favorable to its production than any others. Tight splints, 
blows, diphtheria and other acute maladies, hysteria, and several other 
conditions play a part in its etiology. 

Diagnosis. — Peripheral amesthesia must be diagnosed from the cen- 
tral condition, and it is necessary that we should bear in mind not only 
the anatomical arrangement of the nervous supply, but the coexistence or 
absence of symptoms of central disturbance. Among the latter are loss 
of power, which usually accompanies the anaesthesia, or one or more of the 
many symptoms previously alluded to. 

Trigeminal anaesthesia is, perhaps, more difficult to trace out than that 
of other nerves. Romberg 1 thus enumerates the indications of anaesthesia 
<>f peripheral or central origin : — 

" a. The more the anaesthesia is confined to single filaments of the tri- 
geminus, the more peripheral the seat of the cause will be found to be. 

" b. If the loss of sensation affects a portion of the facial surface, to- 
gether with the corresponding facial cavity, the disease may be assumed 
to involve the sensory fibres of the iifth pair before they separate to be 
distributed to their respective destinations ; in other words, a main divi- 
sion must be affected before; or after its passage through the cranium. 

4t c. When tin; entire sensory tract of the fifth nerve has lost its power, 
ami there are at the same time derangements of the nutritive functions in 
the affected parts, the (lassorian ganglion, or the nerve in its immediate 
vicinity, is the seat of the disease. 

u d. 11" the anaesthesia of the fifth nerve is complicated with disturbed 
functions of adjoining cerebral nerves, it may be assumed that the cause 
i- -rated at the base of the brain." 

Prognosis It is by no means bad after the cause is removed. 

Anaesthesia from pressure is rapidly restored, provided the mechanical 
injury be not too great. If there be division of the nerve, the process ot 
reparation, which rarely extends for more than a few months, is followed by 

a healthy return. With syphilis and the skin diseases the case is different. 

Treatment Electricity offers the best mode of relief. The wire 

brush and faradic current are to be employed every day; ami at the same 

time applications of alternate heat and cold, friction and massage, are 

useful adjui ants. 



1 Romberg. A Manual of the "Nervous Diseases of Man. Sydenham trane 
irol. i. p. 218, et neq. 












TUMORS OF NERVES. 451 



TUMORS OF NERVES. 

Synonym Neuromata. 

A nerve may be the seat of either a syphilitic, cancerous, sarcomatous, 

myxomatous, or other growth which may involve or destroy some point in 
its continuity, or form as a benignant tumor at its point of severance. 

Very little 1ms been written upon this important subjecl ; bu1 among the 
most valuable contributions to the literature of nerve-tumors is an excel- 
lent thesis by Foucault, 1 and various scattered articles by Verneuil.'-' L<" 
Fort, Axenfeld, Roger, and others. 

Nerve-tumors may be classified as neuromata (nervous neuroma of 
Weber) and medullary nerve-tumors, which involve the nervous structure 
itself; and pseudo-neuromata, which include the fibromata, myxomata, 
epithelioma, as well as cysts and tumors of a like character. 

Medullary or ganglion tumors are quite rare, and are of a hyperplastic 
character. Lebert 3 described a neuroma of the superior cervical ganglion, 
in which all traces of true nervous matter had disappeared, and naught 
remained but a fibro-fatty structure. Robin 4 lias found a neuroma in the 
solar plexus, and Yirchow has also brought forward examples. 

Neuroma of nervous fasciculi (nevromes fascicules) include the little 
painful tumors which are met with after amputation, which give rise to 
stum]) neuralgia, and attain the size often of a hazel-nut. Dupuytren, 5 
Cornil 8 and Ranvier, Axmann 7 and AVeissman, 8 have all described their 
appearance and structure, which is fibrous and hard, and the nerve-tubes 
are tortuous and interlaced. 

The pseudo-neuromata are of many varieties. They are developed 
usually in the course of the nerve, and the neurilemma is thickened, and 
should the nerve be cut across, a. white or yellowish hardening will be 
presented. Should the tumor be fibrous, the peculiar microscopical appear- 
ance may be observed. Fibromata rarely exceed the size of an almond; 
but when there is any fluid found, as in the case of fibro-cystic tumors, 
the volume of the enlargement may be much greater. 

The accompanying cut represents a sarcoma of the ulnar nerve, and was 
observed by Demarquay at the Maison Municipale de Sante\ 

Nerve-tumors prefer the nerves of the upper and lower extremities, and 
in the leg the posterior tibial nerve seems to be a common site. It is not 
uncommon to find a great many tumors of this kind existing at the same 
lime In one case reported by Foucault, 1 I<>!) of them were found, but 



1 Sur les Tumeurs des Nerves Mixtes, These, 1872. 

2 Arch, de Med., tome xviii. 1861. 

■ ! Mem. de la Soc. de Clin. 1858, :: fasc. 

1 Comptes Rendua de la Soc. de Biol., 1854. 

5 Loc. cit. 

6 Memoires dr la Soc. Biologie, t. v.. 8d eerie, 1868. 

7 Beit/, zur. mikr. Anat. du Ganglion Nervensystems, Berlin, 1853, 

8 Ueber Nervennenbildung (Zeitschr. f. Rationnelle Med. 1859). 



452 



DISEASES OF THE PERIPHERAL NERVES. 



this is exceptional, and it is probable that multiple neuromata are more 
frequently found in patients who are of the cancerous, syphilitic, or some 
other diathesis. Very often these growths, the result of injury, are 
subcutaneous. In one of my cases the growth was found at the elbow at 
the exposed site of the ulnar nerve, and its origin followed a blow upon 
that part. 

Pain, as I have said, is the prominent symptom of such growths. This 
pain may appear upon the tumor, but usually follows its 
establishment. It may be localized or diffused, or may 
be provoked by pressure on the spot or spots which mark 
the site of the growth; for, when the tumors are multi- 
ple, of course the sensory troubles are equally numerous. 
The pain may radiate from the tumor, or may dart down 
or op the affected nerve. It is not so intense with fibro- 
mata, syphilomata, or sarcomata, or when the tumor is 
composed mainly of true nervous tissue, as is the case in 
stump growths, and in these examples it is productive of 
severe neuralgia of a reflex character. Spasms, perma- 
nent muscular contractions, and sometimes a. peculiar con- 
striction of the thorax of a tetanic nature, with epilepti- 
form seizure and centripetal pain, are indicative of 
certain reflex disturbances. 

Treatment Operation seems to offer the only hope 

of relief, and in stump neuromata re-amputation is often- 
times necessary. It will be found necessary to deeply 
anaesthetize the patient, as the sensibility is so morbidly 
active that ordinary anaesthesia is insufficient. The re- 
moval of a considerable piece of the nerve is advisable, 
for it is not rare to find considerable infiltration or deposit 
in its substance for some distance from the actual growth. 
In syphilis, mercurials and the iodides offer some show 
of relief, and these are the only remedies when the 
growth is deep-seated. Legrand 1 and others have recom- 
mended caustic applications in superficial regions, and 

Siebold pire removed a tumor in this way from the an- 
terior tibial nerve. The operation is rather severe, and 
is attended with doubtful success. 




Sarcomatous Neu- 
roma, Pouoan Lt. i 



1 Gaz. .Med.. Compte-Rendus de I'Aead. des Sciences, 1858. 



FACIAL PARALYSIS. 453 



CHAPTER XVII. 

DISEASES OF THE PERIPHERAL NERVES (Continued). 

LOCAL PARALYSES. 



FACIAL PARALYSIS. 

Synonyms Bell's paralysis; Histrionic paralysis. 

Facial paralysis may be cither double or single, but is more often the 
latter ; and it may depend upon a lesion of a peripheral kind, or one that 
may be seated in the temporal bone, or at any point in its course within 
the cranial cavity, or else at its origin. 

The bilateral form is rare, and is always the result of a central lesion ; 
but the peripheral form is unilateral, and is a very common affection. 

Symptoms The patient, after exposure, may suddenly be attacked; 

and the first intimation he generally has is in the morning, when he arises. 
He then finds his face to be all awry, and his appearance is absurd to the 
last degree; one side being drawn up, while the other is immobile, 
as the muscles of expression are powerless. If he laughs, the contor- 
tion is more marked, and if he attempts to whistle he will find that he 
is utterly unable to do so. The corner of the mouth on the sound side is 
drawn up, and the furrow at the angle of the nose is more marked than 
natural. The opposite side of the face is smooth; and. in the passive state, 
the muscles seem to sag heavily downwards. It is impossible for him to 
corrugate his eyebrows; and the eyelids of the paralyzed side cannot be 
closed, so that dust and foreign substances collect, producing irritation and 
discomfort. This is due to the paralysis of the orbicularis, and at the 
same time 1 the levator palpebrarum contracts and keeps the eyeball exposed. 
The individual is unable to blow out a candle, and articulation is inter- 
fered with to a slight degree. Should he be an old man. any wrinkles 01 
furrows that may have existed on the paralyzed side are effectually effaced, 
ami give that part a most ghastly appearance. Considerable discomfort 
results from the insufficiency of the lower lid, so that the tears, instead of 
being conducted to the lachrymal canal, find their way over the cheek. 

If the lesion be situated within the temporal bone or the cranium, a 

much more extensive paralysis may result. This is indicated by a loss <>f 
power of the muscles of the palate, uvula, and other parts of the faun -. 

When the patient opens his mouth, the palatine arch will be found to be 
altered, the anterior pillars ot* the fauces being Bhorter, BO that one side 



454 



DISEASES OF THE PERIPHERAL NERVES. 



tails lower than the other. 1 The uvula will also be found to be arched, 
the concavity looking towards the sound side. The tongue will then also 
he paralvzed, so that its surface is smooth ; and there may be a dryness of 
the mouth, which results from diminished secretion of saliva. Should 
the portio mollis he affected, there may he, in addition, deafness. If the 
third nerve he affected, as it sometimes is, of course ptosis with dilated 
pupil and paralysis of the recti will result. 

Roux, 9 who was paralyzed in this manner, perceived a metallic taste in 
the right side of the tongue. 

Should the paralysis he bilateral, the patient's features will denote an 
entire laek of expression, and there is not the slightest evidence of any 
emotional excitement expressed, even should the patient be agitated by 
the most intense pleasure or the deepest grief. The muscles are flabby, 
and the face seems more like a mask than what it really is ; and, its is the 
case in advanced progressive muscular atrophy, the only animated features 
are the eyes. 

Romberg 3 describes the appearance of a patient in these words : M In a 
girl of 1G, in Dupuytren's Clinique, who was affected with bilateral para- 
lysis, there was no distortion, but a pendulousness and entire absence of 
motion was perceptible in all the features. The eyelids only closed half, 
the lips stood apart, and played backwards and forwards from the impulse 
of respiration. The expressive countenance bore a serious character, 
which contrasted forcibly with the patient's frame of mind. She was 
heard to laugh aloud, but the laugh appeared to come from behind a mask." 
Sensation is not usually impaired. 

Causes The peripheral form of paralysis may follow exposure to 

cold, rheumatic exudation, and injuries of various kinds. A cause which 
is frequently observed is the chilling of the face by a blast of cold wind; 
and the frequency of this cause has led to the adoption by the French 
writers of the term, "Coup de vent." I have met with many cases in 
which the paralysis took place after a railroad journey, the individual 
having sat by an open window. 

hi our instance the patient, who was a. young lady, had been dancing 
violently, and had afterwards gone into a damp conservatory to cool off; 
the palsv was shortly afterwards noticed. 

Rheumatic exudations may produce pressure upon some of the nerve- 
twigS, or a.n attack of parotitis may result in pressure upon the cervico- 



1 Hughlings Jackson (London Lancet, Jan. i<;. 1875) does not consider that 
deviation of the palate occurs in uncomplicated disease of the portio dura, and he 
does not believe deviation of the uvula to be uncommon in healthy people. 
Troltsch sayi that tin- levator palati is supplied l>\ the vagus, which explains 
tin- phenomena witnessed by Jackson, viz., marked pals} of one side of the 
palate, with palsj of the vocal corfl on the same side, as a result of intracranial 
disease. ThU case, however, 40 exceptional. 

Descot. Diss, surlee Affections locales dea Nerfs, Paris, 1825, p. 831. 

1 Op. <-it.. vol. ii. p. 268. 



FACIAL PARALYSIS. 455 

facial branch. Injuries of the nerve, whether such us follow coarse trau- 
matism or accidental section of the nerve during a surgical operation, are 
sometimes the cause of the paralysis. 

Weir Mitchell relates several cases of this kind. Three of these 
(Cases 61, 62, and 63) followed gunshot wounds. 1 In one the portio dura 
of the left side was injured, and as a consequence there were facial palsy, 
impaired speech, and loss of gustation. Hearing was impaired from 
shock transmitted to the auditory nerve. Sir Charles Bell* divided the 
facial in removing a tumor, and other cases are reported by various 
surgeons. 

Carious disease, as well as fractures of the temporal hone, often pro- 
duces paralysis, either by pressure, by the products of inflammation, or by 
direct contusion. 

Tumors and various aural growths are occasionally causes of this second 
form of facial palsy; and Romberg 3 reports a case, seen by Henle, in which 
a tuberculous deposit was found beneath the middle lobe of the brain, with 
destruction of the petrous portion of the temporal hone; and Froriep 4 also 
found a deposit of tuberculous matter in the Fallopian canal, with caries 
of the petrous portion of the bone. 

Degeneration, exudation, and tumor in or near the [tons may also be 
the cause of the deep form. 

The following case is an example of deep-seated paralysis, evidently 
dependent upon aural disease. 

Samuel M., aged 27 ; United States, canal boatman ; came to me July 
3, 1876. Three days before the first visit, after exposure while washing 
the decks of his boat, he became paralyzed. He had had earache before 
for several days, but did not consider it of sufficient moment to quit work ; 
and his first intimation of trouble was the discomfort produced by par- 
ticles of dust which blew in his eye. He could not close his left eye, and 
on looking in the glass he discovered the paralysis. There was no pain, 
nor any subjective sensation of any kind. He found that he could not 
laugh, nor blow his nose, and when he attempted the latter " the wind 
came out of his mouth." When I saw him there was paralysis of both 
branches of the seventh nerve. Hearing was very imperfect, and he could 
not count the ticks when the watch was pressed to the Lett ear. The left 
palatine arch was obliterated, and he could not fully protrude the tongue, 
which was quite dry. The left side of the face is quite Hat, and the mus- 
cles of the other side act to such a degree as to draw up the right corner 
of the mouth, producing the characteristic deformity. When lie opens 
his mouth, the orifice is unsymmetrical. lie cannot whistle or expecto- 
rate. He cannot close the left eve, hut when he attempts to do so the hall 
is drawn upwards, SO that the sclerotic is shown to a great extent. Con- 
tractility to both currents fair; mediate and immediate galvanization are fol- 
lowed by muscular response, lie has some earache. When the electrode 

1 Injuries of Nerves, etc., p. 892, <t seq. 

2 The Nervous System of the llinn.ui Body, 3d ed., 1836, p. 56. 

8 Romberg, op. cit., p. 272. 

4 Massalien, Diss, [naugur, de Nervo Paciali, Berolin. 1836. 



456 



DISEASES OF THE PERIPHERAL NERVES. 



is passed over the superficial points of the fifth, there is decided pain, no 
anaesthesia : force of masseter muscles tested by putting the dynamometer 
bulb between the teeth and interposing two pieces of wood; no loss of 
power as compared with my own attempts. Tympanum red; and I infer 
that there is middle ear disease. R. Potass, iodid. and syringing ear with 
warm water. 

July 6. lias had intense pain in the left ear, throbbing and pains which 
radiate over the head. Pressure over mastoid process gives great distress, 
as doc- electrization. Leeching to inner tragus. 

\)th. Says that there was a discharge of pus hist night. After syringing 
out I find a perforated tympanum. Stopped iodide, and ordered syringing 
witli warm water and glycerin. 

[3th. Discharge from ear much less. Used iodoform powder locally. 
Muscles do not respond so well to either current. Iodide renewed. 

17th. No response to current. Faradized nevertheless. 

\\)th. 21st, '2:)(/, '21 't.h. Used iodoform. Aural disease almost well, but 
patient still deaf. Muscles still inactive. 

30th. Tested sense of taste, and find it markedly affected ; his tongue 
seems quite smooth. He hashad from the first some clumsiness in speech. 

Oct 1*77. There has been very slight improvement since the last 
entry. The facial deformity is not so great. Pie is still deaf. His speech 
is clear, but he cannot whistle as yet. The muscles do not respond to the 
currents. II<" sutlers great annoyance from the accumulation of saliva, 
and when he expectorates he soils his clothing. 

Pathology The anatomical distribution of the facial nerve and its 

connection with other nerves may be referred to in illustration of the pa- 
thology of the affection. Beginning externally, we find that the facial 
nerve supplies the muscles of the face, the malar branches innervating the 
orbicular muscles of the eyes; that the infra-orbital supply the buccina- 
tor and orbicularis muscles, and the levator labii superioris aheque nasi 
muscles; while the cervico-facial division of the nerve passes through the 
parotid gland, and supplies the muscles of the mouth and lower jaw ; conse- 
quently a Lesion of any of these branches, or of the main trunk at its exit 
from the stylo-mastoid foramen, would be followed simply by paresis of 
the facial muscles. Should the lesion take place in the aqueductUS Fallopii, 
or behind the geniculate ganglion, we would find as a consequence paralysis 
of the muscles of the face, the tongue, through paralysis of the chorda 
tympani, and paralysis of the palate muscles, through paralysis of the larger 
superficial petrosal nerve, which runs from the geniculate ganglion to the 
spheno-palatine ganglion. Deep lesions may involve the third nerve, and 
perhaps the sixth. The lesions and their results maybe thus arranged: — 



FACIAL PARALYM-. 457 

Paralysis of the Seventh Nerve. 

EXTERNAL THIRD. MIDDLE THIRD. INTERNAL THIRD. 

Facial Branches. Petrosal nerves, Auditory Possibly lesion un 

(Portio mollis), Chorda the .' J >d and 6th nerves. 

Paralysis of the Tympani. and then besides all of the 

Orbicularis palpebrarum, foregoing then- may be 

Corrugator supercilii, Paralysis of all the fore- paralysis of the Levator 

Levator labii, etc., going as well as lingualis, palpebral and the recti 

Pyramidalis nasi, tensor and laxator tym- muscli 

IHagastric, pani, levator palati, and 

Buccinator, azygos uvulae. 
Orbicularis oris. 
Depressor anguli oris, 
Levator labii inf. 

Diagnosis. — The appearance of facial paralysis may be a source of 
alarm to the individual, who is ready to believe it a feature of cerebral 
hemorrhage or deep organic trouble. It is much more profound, however, 
than the form which accompanies cerebral hemorrhage ; and generally 
there is hemiplegia of the extremities in the latter disease. In this form 
it is impossible for the patient to shut the affected eye. while in the other 
disease there is usually no difficulty in so doing. Sensation is also affected 
in the paralysis from cerebral hemorrhage, and it is not unusual to find 
ptosis. The matter of importance, however, is the diagnosis of the variety 
of facial palsy, superficial or deep ; and we may avail ourselves of elec- 
tricity in settling this point. 

If the paralysis be peripheral, the muscles retain their contractility for 
several weeks. If, on the contrary, the lesion be central, or in a nerve-trunk, 
they lose their power of response to a faradic current in a few days, and 
later to even a galvanic current, and the muscles finally become atrophied. 
If the paralysis be due to bulbar disease, the appearance of symptoms in- 
dicating impairment of other nerves and an eventual fatal termination 
should settle the nature of the affection, and enable us to make a prognosis. 
The existence of carious disease and its indications, the complication of 
deafness, and the coexistence of indications of deep trouble, should be 
all taken into account. 

Prognosis The prognosis of the peripheral form of the diseasi ifi 

very good, and under proper treatment the paralyzed muscles may be 
rapidly restored. There is generally early loss of muscular contractility, 
which only the galvanic current can restore. If there is no response to 
electrical excitement, and the muscles of the paralyzed side are wasted and 

Contracted, there is little to be hoped lor. I consider that more depends 

upon the early adoption of electrical treatment than anything else; and it 

there lie a delay in the selection of remedies, and in the attempts to re-tore 

the muscles by mechanical support and electricity, the prognosis, which 

may have been favorable in the beginning, become- less and less BO, the 

longer action is delayed. 



458 



DISEASES OF THE PERIPHERAL NERVES, 






Syphilis is a favorable element if the paralysis be due to deep lesions; 
but, if it be caused by brain-tumors, exudations, or degeneration, there is 
scarcely any hope. 

Treatment It is necessary in this disease to direct the treatment 

not only to the cause, when one can be found, but also to the restoration 
of the paralyzed museles. 

Should rheumatism exist, we are to employ colchicum and iodide of 
potassium : if syphilis, the specifics which are at our disposal ; and if there 
be caries, we arc to improve the patient's general health by nourishment 
and stimulants, and to apply such local treatment as may seem proper. 
The medicaments which will be found to be of service for the direct 
treatment of the paralysis are strychnia, iron, and quinine. Electricity is 
of great service ; and we may begin with the galvanic current and use the 
faradic as soon as it can produce contractions. The negative pole of the 
galvanic battery should be placed behind the ear, and the positive pole 
passed over the different facial muscles. The glass "bain electrique" 
should be applied to the eye, so that the orbicularis shall be brought under 
the influence of the current. 

The mechanical treatment of facial paralysis has been advocated by 
Detmold, and with admirable results. A piece of tin wire is bent at both 
ends (Fig. 52), and one end is passed over the ear and the other hooked in 
the angle of the mouth, so that the muscles of the paralyzed side shall be 
supported. In several of Detmold's cases it was found to work exceed- 
ingly well. 

Fig. 52. 




Wire Hook for the Treatment of Facial Paralysis. 



Tin- apparatus may be worn at night or during the day, and does not 

give ih<' patient any discomforl whatever. 

Dr. Van Bibber has suggested, in the treatment of ptosis, the use of a 

Small Strip of COUrl plaster, which IS affixed to the upper lid and to the 

forehead :ih<>\ e« 



FACIAL PARALYSIS. 459 

I may append a case of facial palsy of a syphilitic nature cured by 
electricity in a remarkably short space of time. 

W. 0. L, 30 years; United States, boatman. Previous history. He 
has never heen seriously ill, but ten years ago he bad a chancre, followed 
by marked secondary symptoms. The only other ailment was a severe 
attack of rheumatism, occurring a year before. This was undoubtedly ;i 
secondary symptom. I lis present difficulty began three months ago. At 
night he was disturbed by intense cephalic pains, dizziness, and disordered 
vision. For several days the pains were steady and mosl violent under 
either temple ; he was also annoyed by post-aural pains, lie then found 
that his hearing was becoming less acute, till the lesion finally occurred. 
This took place towards the latter part of July, 1870. He awoke in the 
morning and felt a pain in the head, attended by swelling and puffiness in 
the face. His attention was called by several of his associates to the 
"crookedness" of his face. He looked in the glass, and saw the drooping 
of the left side of the face, with complete paralysis of the muscles at the 
corner of the mouth ; then followed total loss of hearing, and he could not 
appreciate the loudest noises when the sound ear was closed. The 
paralysis increased every day. 

A few days after this the eyelid drooped, and he found it impossible to 
open or completely shut the eye. It became congested and irritated, and 
he experienced a burning sensation, with photophobia. His condition 
grew gradually worse, till he was compelled to leave his employment and 
seek medical aid. He never had had otorrhaja or ear affections of any 
kind, nor had been paralyzed. His habits were good, and his hereditary 
history favorable. When he applied to me, I found paralysis of the entire 
seventh nerve, motor ocularis, and disturbance of the sympathetic of the 
eye. There was no appreciable power in the orbicularis oris, levator 
labii superioris et alseque nasi, or other muscles. He could hardly insert 
the finger in the mouth without pulling down the jaw with the other 
hand. He experienced mastication and deglutition from involvement of 
the left side of the tongue, which, when protruded, inclined to the right 
side. With this there was indistinct articulation, and I was led to infer 
paralysis of the lingualis muscle. From the patient's previous history I 
was led to suppose that syphilis was the primary cause of the trouble, and, 
from the depth of the lesion, that the seventh nerve was paralyzed at a 
point above its division. From the specific features of his case I deemed 
the iodide of potassium to be the best remedy, and he was therefore put 
upon grs. v thrice daily. Hypodermic injections of strychnia and atropia 
(^ 5 of a grain of the former to ^ of the latter) did much good in relie\ ing 
the severe cephalalgia. Localized galvanization was resorted to. and both 
the primary and secondary currents used. After the nerve and it< 
branches had been pencilled over with stick caustic, one electrode was 
applied to the ramifications of the nerve, while the other was placed over 
the mastoid process. So successful was this treatment that after a daily 

seance lasting twenty minutes, in three weeks die patient's face was much 

more symmetrical, and the act of mastication improved. The pains like- 
wise disappeared under the same current. Occasional directions of this 
and the faradic current over the eyelid did much toward the improvement 
of sight. 

It now occurred to me that Matteucci's experiment on the ear might be 
followed by gratifying results; BO its cavity was filled with water, and one 
of the battery-wires, finely Covered with sponge, was gently introduced 



460 DISEASES OF THE PERIPHERAL NERVES. 

into tlu' external meatus. After four weeks his hearing was so markedly 
improved that he easily distinguished loud voices when the sound ear was 
closed. 

November 1 "2 (seven weeks after commencement of treatment). During 
the application of the current the face resumed its expression, and he was 
able to close his eye completely. He is greatly improved; injections dis- 
continued, lie has almost complete control over the levator palpebral — 
this is marked in the morning; articulation good. 

'l^tlt. Has now taken the battery for nearly ten weeks, and is about 
to discontinue treatment. The face is perfectly symmetrical, and the 
hearing nearly as perfect as ever. The only remaining disfigurement is a 
slight drooping of the eyelid on the affected side ; appetite good, and, 
though emaciated at first, he has now completely regained his former good 
condition. 



TRAUMATIC PARALYSIS. 

Under this head I propose to speak of those forms of lost power de- 
pendent upon partial or complete nerve-section, or pressure made upon a 
nerve in its course, such as is often seen in a familiar form known as 
decubitus paralysis, as well as in the loss of motility produced by cold or 
other influences which may affect the ramifications at the peripheral end 
of a nerve-trunk. There is no regularity either in the form of invasion, 
tin.' extent of the paralysis, or its locality. Suffice it to say, that both upper 
and lower extremities may be affected, the upper especially, and that such 
paralysis is not bilateral. The liability of the upper extremities to this 
accident is probably explained by their use in many of the necessary 
action- of everyday life. These forms of paralysis may be divided into 
three groups: (1) Paralysis following section or destruction of a nerve- 
trunk or its branches; (2) Paralysis following pressure ; (3) Paralysis 
following cold, or general disease. 

Division of a Nerve-trunk If the section be complete, the paralysis 

will be equally complete and immediate. There is likely to be, in addi- 
tion to I.m Bensation and motion in the muscle supplied by the nerve, 
various trophic defects, which may consist in exfoliation of the skin, 
and in changes in the condition of the nails, which become curved, crenated, 

and deformed; and sometimes eruptions. The loss of motion, of course, 

will depend upon the importance of the group of muscles supplied by (he 

nerve; and it does not follow, by any means, that the member is utterly 
useless, :i- some muscles may escape the paralysis. Should suppuration 
and inflammation occur at the wound, there may be various disturbances 
of sensation, and also lowered temperature in the paralyzed side. 

Contusions and Punctured Wounds The injuries produced by Licks, 

or direcl violence, when the skin is not broken, are very commonly fol- 
lowed by traumatic paralysis.^ These are likely to occur when the nerve 
rests upon some bony prominence, and when there is no muscular or 
other cushion to make the blow Less slight. I can recall cases of this 



TRAUMATIC PARALYSIS. 401 

kind, one in particular, where the individual fell in the street, striking 
his elbow upon a projecting stone. There were no immediate symptoms 
except a tingling and sharp pain, but in a few days there was loss of 
power, and some hyperesthesia of the forearm. 

The experience of surgeons furnishes us with numerous examples of 
peripheral paralysis from dislocation. Dr. S. G. Webber, 1 of Boston, has 
brought forward several very interesting cases of this variety, with disloca- 
tion of the humerus; and Onimus and Legros 3 a case which Webber pre- 
sents in his article to illustrate a form of paralysis following dislocation of 
the femur : — 

" A man, forty-six years of age, suffered an ilio-ischiatic dislocation of 
the femur, which was produced by violence exerted by falling rocks and 
earth. Severe pain, anaesthesia, and immobility of the leg existed at first, 
but the pain subsequently disappeared, and the anaesthesia remained. 
After an attack of facial erysipelas the pain in the legs returned. Five 
months later the left leg was found to be cold and smaller than the other, 
and (edematous about the tibio-tarsal joint. The leg could be flexed and 
raised, but the foot could not be raised nor the toes extended. Sensation 
was diminished, as was electro-muscular contractility, especially in the 
flexors and extensors of the leg, the muscles of the calf and the peronei, as 
well as the tibialis anticus and extensor communis." 

In Webber's case of paralysis following dislocation of the humerus, the 
biceps and deltoid were most affected, and there was anaesthesia over the 
deltoid. 

J. S. came to the N. Y. State Hospital for Disease of the Nervous Sys- 
tem, June 9, 1871, with the following history : During an altercation 
with a fellow-laborer lie was thrown off a scaffold, and dragged by his 
right arm for some distance. When he arose he found that the whole 
arm was very painful, and a few mornings afterwards the right wrist be- 
came very weak, and he was unable to grasp any object or move his 
lingers. Sensation was unimpaired. 

Nerve-injury following dislocation is not always the same, there being in 
some cases simply pressure, and in others rupture of the nerves by strain ; 
and of course the prognosis depends much upon the fact whether there be 
simple contusion or actual laceration, as there was in a case reported by 
Hilton. 

Pressure upon nerves may be made by the products of inflammation, 
cicatrices, callous tumors, or by improperly arranged splints, or the press- 
ure of a, crutch or some hard substance, or by the maintenance o\' a con- 
strained position for an extended period. The production of a. periostitis 
may exert pressure 1 upon a nerve-trunk in some bony canal, or an exuda- 
tion which makes compression either in its course or at ils ramification. 
There is always some painful indication ai first, and occasionally a neu- 



1 Boston Med. and Surg. Journal, Dec. is, is:::. 

2 Traitc d'ElectricitS Medicate, Paris. 1872. 



40*2 DISEASES OF THE PERIPHERAL NERVES. 

litis, after which the loss of power takes place. Movement of the limb 
aggravates this pain, or pressure over the nerve has the same effect. 
Pressure from a cicatrix is quite rare, and it is only "when very extensive 
contraction of the cicatrix occurs that any such condition of affairs can 
exist. So. too, is pressure from callus an uncommon cause of paralysis, 
and but a few cases of this kind have been mentioned. 

The pressure of the nerve by a tumor may be rirst indicated by hyper- 
aesthesia, and secondarily by loss of motion and sensation, and the dura- 
tion of the first stage depends upon the site of the tumor, its rapidity of 
growth, and the room for increase in size. In certain situations where 
there are bony eminences or cavities, and where there is no room for ex- 
pansion of the mass without consequent nerve-compression, the loss of 
function is very quickly produced. 

By far the most familiar form of peripheral paralysis is that which fol- 
lows the compression of nerves during the continued maintenance of a 
constrained position, the nerve-trunk being pressed against some bony 
eminence, or impinged upon by some tendon or muscular mass. The 
common modes of onset maybe the following: The patient falls asleep 
with his elbow resting upon some hard substance, and awakens to find his 
forearm devoid of power. The following are examples : — 

M. P. went upon a spree, and when he became sober found his arm 
numb and cold, and devoid of power ; muscles respond to faradic current : 
unable to force dynamometer column to 6. 

T. W"., four years ago, fell asleep with bis left arm under his head; 
when he awoke his arm was numb and powerless. Soon after formication 
appeared. After seven months, pain, which subsequently became parox- 
ysmal, began in the arm, coming on every two or three minutes. Re- 
sponse only to galvanic current. 

In one case, reported by Webber, the paralysis was the result of carry- 
ing a basket of lemons, pressure being made on the radial nerve. 

Mitchell 1 speaks of paralysis of this kind resulting from the most simple 
causes. In one ease, that of a child, pressure was made by a string pass- 
ing over the finger. And in other cases reported by Brinton, 8 it was 
found that the paralysis followed the rough use of a pair of cord handcuffs 
upon a prisoner who was being taken to the police station. 

The use of the forceps is occasionally attended by paralysis of the 
facial nerves, the blades of the forceps making pressure upon the portia 
dura. In these Ca8ea there i^ paralysis of the facial muscles, an inability 
to nurse owing to the paralysis of the orbicularis oris, but no palatine loss of 

power, which serves to diagnose the effects from the form due to intracra- 
nial trouble. The mother may be paralyzed from pressure by the forceps 
exerted upon the peh ic nerves, hut this accident is an extremely rare one. 

Accumulation of feces produces paralysis generally byreflex irritation. 

;in<l rarely bj direct pressure* l'>ut few of such cases have been reported, 



Op. <ii.. p. i 26. ■ U. S. Sun. Com. Reports. 



TRAUMATIC PARALYSIS. 463 

and of these, one detailed by Portal 1 is of great interest, from the fact that 
spinal curvature favored the accumulation of feces and the exertion of 
pressure upon the nerves of the lumbar plexus. 

Cold or malaria may also be causes of a form of peripheral paralysis. 
In speaking of facial palsy I have alluded to the variety known as the 
" Coup de vent." This sudden origin from exposure to damp and wind is, 
however, much more rare than that which follows intense cold. I have 
had several eases of this latter kind among draymen, sailors, and others 
who have been obliged to work for a protracted period in an exposed 
place. There is at first a numbness, and afterwards a complete loss of 
power, which may be bilateral. 

In peripheral paralysis there is a diminution of electro-muscular con- 
tractility after the first few days, and if there be complete section of tin- 
nerve this susceptibility to electric stimulation is lost, first to the faradic, and 
at the end of a week or two to galvanic stimulation. If a few fibres 
remain intact, it will be found that certain muscles are unaffected, and of 
course electrical irritation meets with a ready response. Changes of color 
in the paralyzed limbs are the rule, and there may be within an extensive 
blanching or patches of discoloration dependent upon the irregular circula- 
tion. Analgesia and anaesthesia generally exist in some degree, while 
changes of temperature are not so readily perceived as on the sound side. 

As the nerve is restored, electro-muscular contractility returns, and finally 
the patient is enabled to produce contraction at will. 

Arlong and Tripier 2 have alluded to the rapid return of sensibility in 
distal parts after nerve-section, and explain it by the theory that there 
are anastomoses between the severed portions, but this view has not been 
generally received. 

Diagnosis and Prognosis Progressive muscular atrophy and 

cerebral diseases are to be disposed of, and if we see the case after the 
onset we may be deceived. In the former it must be remembered that 
then; are fibrillary contractions, and that the atrophy precedes the paralysis. 
The electro-muscular contractility is also preserved for some time. 

In cerebral paralysis the electro-muscular contractility is preserved, and 
if anything exaggerated. Cerebral palsies do not involve such exten- 
sive sensory impairment. Spinal paralyses are usually bilateral, a fact 
which distinguishes them from peripheral troubles. 

Mitchell also alludes to the fact pointed out on a previous page, that in 
peripheral palsies there is none of the delay in transmission of impression 
which characterizes either spinal or cerebral trouble. 

WestphaP has recently reviewed an admirable article by Vulpian,' in 

which he refers lo the various interesting pathological changes which 
follow division of spinal nerves. His experiments were made to determine 



! Cours d'Anatomie MSdicale, t. iv. p. 276, quoted b) .Mitchell. 
8 Journal de l'Anatomie e1 Phys., etc., March and \pril. l s 7 o . 
8 Centralblatl fur Med. Wiss.. July 13, t s 7 -_> . 
4 Comptes Rendus, 1872, No. 15. 



464 



DISEASES OF THE PERIPHERAL NERVES. 



the muscle-changes which follow separatum from the cord. His conclu- 
sions may be thus summed up: — 

It' a spinal nerve be cut through at any point between the spinal gan- 
glion and the periphery, the nerve-fibres of the central portion undergo 
atrophy en masse, without their individual character being altered; but 
the peripheral part of the nerve-trunk undergoes what Vulpian calls 
" histopathic change," i. e., a breaking up or " splitting" of the medullary 
substance. 

Atrophy of muscles follows section of a motor nerve ; and, in addition 
to this, electric contractility is impaired. 

The absence of central symptoms of any kind, the loss of both motion 
and sensation in a limited area, absence of reflex contractions when the 
sensory fibres are irritated, and voluntary motion lost, are evidences of 
the peripheral nature of these paralyses. 

Treatment Traumatic paralysis, like the facial form, should be 

treated with an idea of removing the cause should it exist, and afterwards 
restoring the integrity of the nerve and muscles, and preventing muscular 
atrophy. If the nerve-trunk be severed, of course all we can do is to await 
the union of the divided ends. If a tumor makes the destructive pressure, 
it should be removed if possible. It is hardly necessary to allude to the 
paralysis following dislocations, for of course the surgical proceeding, which 
is indicated at first, is the reduction of the luxated bones, and this should 
be done as early as possible. 

In the management of paralysis, which, Desplats 1 says, may be due to 
pressure made by osseous enlargements, iodide of iron and other proper 
remedies, with cod-liver oil, are to be employed. If there be neuritis, it 
should be met with counter-irritation, emollient applications, or leeches. 

General supporting treatment may be necessary if there be a depraved 
condition of the system. 

The three valuable local forms of treatment are: 1. Electricity; 2, 
Strychnia, internally or hypodermically ; 3. Massage. 

The first agent may be used as early as possible. If one current will 
not produce contractions, we may use the other; and, if complete sever- 
ance of the nerve has taken place, it may be necessary to employ gal- 
vanism. Faradism is especially valuable should there be anaesthesia, and 
may be applied to the cutaneous surface. The galvanic current may also 

he used at the same tine-. -<» that one electrode shall be applied to the 

spine, and the other to the extremity. The individual muscles are to be 
subjected i<» daily galvanic stimulation. 

The production of pain IS unnecessary, and I may repeat the clinical 
pule BO tersely applied by II. C. Wood r « Always -elect the current which 

produces the most muscular contractions, with the leasl amount of pain." 
Pain and over-fatigue, which follow the use of a strong current, are very 



1 I >es Paralj sea Peripheriq 
> Phila. Med. 'limes Feb. 



ies. Paris, 1876, p. 45. 

20, is 7."). 



TRAUMATIC PARALYSIS. 405 

apt to thwart any probable success. The seance should last not more than 
ten or fifteen minutes every day. 

An excellent method of treatment is to place the paralyzed limb in a 
vessel of warm salt water, and to introduce therein two metallic plates 
connected with a faradic machine. If there be neuritis, electricity does 
great harm and should not be used. 

I have repeatedly witnessed the beneficial results which followed the 
use of hypodermic injections of strychnia (F. 30). An injection of ^ of 
a grain may be thrown under the skin over the paralyzed muscles. This 
may be repeated daily ; and I have sometimes seen its good effects when 
electricity was without avail. 

The use of " massage" should be employed in conjunction with the other 
treatment, and the muscles should be separately kneaded and rubbed for a 
half hour each day. This auxiliary treatment is of immense value when 
there is suspected rheumatic exudation. 

I have often employed apparatus by which the paralyzed limb could be 
subjected to warmth, and for this purpose have used a heated drain-pipe 
lined with cotton-wool, such as has been spoken of on another page. Into 
this the patient was directed to place his arm and allow it to remain for 
an hour or so each day. The paralyzed limb may be wrapped in cotton 
and oil silk, or India-rubber tissue. 

The union of divided ends has been resorted to by Tillaux, 1 Xelaton, 
and others, and with a great deal of success. In Tillaux's case the 
median nerve M r as united by sutures, and w T ithin a day or two the patient 
was able to move his thumb, and there was some return of sensation. 

^Mitchell 2 employs the following method : He carries a needle, threaded 
with one or two threads, through the loose tissue which is related to the 
nerve-sheath. The loops are drawn with care, so that the ends are 
approximated. Hot and cold douches and electricity are subsequently 
used. 

In some cases we may use Van Bibber's apparatus. 

Van Bibber presented the following case to the Maryland Medico- 
Chirurgical Society which illustrated the beneficial results of treatment of 
this kind : — 

"A youth, set. 10, about three years ago sustained a fracture of the right 
radius, which resulted in paralysis and atrophy of the extensor group of 
muscles. He lirst came under my observation about three months ago, 
when I found the following condition of the arm : radius curved : hand 
flexed, and the flexors acting inordinately ; complete atrophy of the 
extensor muscles, it being impossible for him to move his hand : no 
response of the muscles to electricity ; and the skin tightly bound over the 
radius. The treatment has consisted in rubbing and pinching the affected 
muscles, the application of electricity, and the use of the artificial muscle, 
which is nothing more than an elastic tubing fixed to the back of the arm. 

1 Quoted by Weir Mitchell, Dis. and Inj. o\ Nerves, p. 2 3. 

2 Ibid., p. 248. 
30 



466 



DISEASES OF THE PERIPHERAL NERVES. 



The results of treatment have been very satisfactory ; the lost muscles 
have been restored, the skin has regained its former tone and elasticity, 
and the motion is fast returning." 

I may in conclusion present a case which was reported by Bernhardt, 
in which electricity was used. 

" L., 1 4o years old ; dislocated his left humerus by falling on his left 
shoulder. lie had pain in the shoulder, and found it impossible to use his 
arm. and that felt cold. The dislocation was found to be subcoracoid, and 
after eight days it was reduced. The pain ceased, but the paralysis con- 
tinued. In the palm of the hand there was, after three weeks, consider- 
able sealing of the epidermis. Pressure on the shoulder was not painful, 
but a strong grasp of the triceps and of the muscles of the forearm was 
unpleasant. Occasionally there was a sense of formication from the 
middle of the arm down the extensor side of the forearm to the end of the 
tin-crs. The left arm could be raised in a straight line forward about 
half a foot, but could not be carried backward nor across the breast. The 
forearm could not be bent on the arm ; only the supinator longus was 
rendered tense. Extension was impossible ; supination was slight. The 
hand could be raised somewhat. Abduction and adduction of the hand, 
flexion and extension of the fingers, were impossible. The prick of a. 
needle was felt to the upper border of the lower third of the arm on both 
sides equally. In the lower third of the left arm, in the elbow-joint, and 
the upper part of the forearm, the skin is more sensitive on the right than 
the left. In the rest of the forearm, in the hand ami fingers, the sensa- 
tion is a little less on the left than right, but nearly equal. The muscles 
of the arm and forearm, of the hand and finger, as well as the deltoid, 
showed only the slightest reaction to the induction current. Likewise the 
use of a very strong galvanic current either to nerve or muscle, by 
opening or closing, failed to produce contraction. 

"From the 5th of January, every other day, tin 1 patient was treated 
with a strong galvanic current, the anode and the cathode being plaeed on 
the paralyzed muscles. After four weeks he could raise the arm forty 
degrees, also some distance backward, so as to touch the right shoulder 
with the left hand. Also, he could bend the forearm on the arm, and had 
some motion in the hand and fingers. Alter eight weeks more motion 
was nearly restored." 



DIPHTHERITIC PARALYSIS. 

Diphtheritic paralysis may either lake place as a feature of the diph- 
theritic attack, or it may appear during convalescence, or even several 

week- after recovery. The paralysis is generally bilateral, and does not 

last any great Length of time if the throat is alone affected, and rarely 

exceeds ten or fifteen days in duration. Should the loss of power begin 

at the Mime lime as the acute disease, the progress of the ea.se is much 

more apt t<> be fa.\ orable, and the paralysis disappears in a shorter spare 

of time than it it occurs at a period Subsequent to the disease. 



Reported bj M. Bernhardt, Berliner Klinische Wochenschrift, No. .">, 1871 



DIPHTHERITIC PARALYSIS. 407 

Lanne states that a marked and sudden increase of temperature during 
the diphtheritic attack or convalescence is indicative of paralysis. 

The paralysis may be simply motorial, or there may be a corresponding 
loss of sensation which is variable in extent. 

The muscles of the throat are usually involved, so that regurgitation of 
fluids takes place through the nose, or there may be certain phenomena 
which are so well marked in bulbar paralysis, in which the lesion is one 
of a destructive character. When the limbs are paralyzed, there may be, 
according to Brenner, movements of a choreic character which depend 
upon the irregularity of the paralysis, the antagonism of certain groups of 
muscles being abolished. The organs of special sense are not unusually 
involved. There may be paralysis of the muscles of accommodation, 1 
neuro-retinitis, and sometimes ptosis. Deafness is not rare, and in one 
of my own cases there had been tinnitus immediately preceding the 
deafness. 

The following case is of a very interesting nature, from the fact that it 
is reported by the patient himself, who is a medical man. 2 

" In October, 1875, being twenty-six years of age and in good health, 
after two months' constant exposure to diphtheria, I was inoculated from 
a child two years old, who, on examination, coughed portions of the mem- 
brane into my face. Six days after this exposure I was seized with a chill, 
followed the next day (October 28th) by the appearance of a diphtheritic 
deposit on one tonsil. The deposit was limited to the tonsils and back 
part of the pharynx, and in nine days disappeared. Exhaustion and great 
gastric irritability retarded convalescence. Four weeks passed before I 
was able to sit up. Two weeks after convalescence was declared, a sharp. 
lancinating pain in the left axilla was noticed, recurring two or three times 
at short intervals. In a few days, after seeing visitors or talking a little, 
severe and constant pain in the elbow-joints occurred, which soon ex- 
tended to the muscles of the arm and chest. After resting, these pains 
diminished or disappeared, and in a week entirely ceased. On attempting 
to rise, my limbs seemed surprisingly weak, but at the expiration of the 
sixth week a short walk was possible. After a brief period of improve- 
ment my legs began to grow uncertain and weak, and by December 1 ( >t li 
I could take but a few steps. At this time a partial loss of sensation came 
on, beginning in the feet and gradually progressing to the trunk, together 
with a feeling of coldness in the i'vx't, which, however, were not cold to the 
touch. This numbness increased faster than the loss of motion. Soon 
after its appearance in the lower extremities the ends of the lingers lost 
their sense of touch, the loss of power also extending in a week to the 
elbows, and at no time greatly affecting the arm. Loss of motion in the 
lingers and forearm accompanied it and increased for some weeks. The 
mouth, tongue, and portions of the face lost their sensitiveness at the same 
time and to the same degree. In a few days my voice grew thick, and 
was soon like that caused by cleft palate. The soft palate and uvula hang 
loosely in the mouth, and on attempting to swallow fluids they were regur- 
gitated through the nares. Dimness of vision for a short time prevented 



1 See cases reported by Hutchinson, Lancet, dan. :. 1871. 

2 Dr. A. F. Reed, Boston Medical and Surgical Journal, Julj L3, i^:*;. 



4G8 DISEASES OF THE PERIPHERAL NERVES. 

reading. In three weeks my voice, then at times unintelligible, grew sud- 
denly better, and in four or live days was restored. The difficulty in swal- 
lowing also soon disappeared. The loss of motion and sensation in both 
arms and legs increased. In walking I seemed to be on velvet ; there was 
a Bensation of coldness in my feet, and at first the circulation was retarded. 
The general loss of power was progressive until February 1st. It was 
then impossible for me to stand alone even when lifted up, to raise myself 
an inch from the chair by my arm. to bring my thumb and forefinger 
together, or to exercise my strength in any part. The toes hung lifeless, 
and no reflex action was produced on tickling the sole of the foot. The 
urine was voided with difficulty, and the power of erection was gone. 
The interosseous muscles were wholly paralyzed, though still reacting to 
the faradic current. The fingers were drawn up when the hand was at 
rest, but only by great effort could be straightened out again. The mus- 
cles of the arms were much weakened, but with those of the thigh retained 
more power than the rest. They were also the last to lose and the first to 
gain motion. All these muscles were more or less responsive to the faradic 
current, the gastrocnemius least of alL During the weeks previous and 
at this date my appetite was excellent, and my food well digested. From 
this time an improvement as general as the invasion was noticed. In one 
week I could lift my body in the chair an inch or two, and when standing 
felt more secure. In two weeks I could raise myself up from the chair mainly 
by my arms, and undressed without aid. At the end of three weeks I 
Could walk about the room aided by a cane, and wrote legibly. The diffi- 
culty in voiding the urine and loss of power of erection had by this time 
gone. In four weeks I walked out for a short distance, and in two weeks 
more all paralysis had disappeared, leaving some neuralgic pains in the 
knees and feet, which lasted but a short time. On April 1st I walked 
several miles without great fatigue. Atmospheric changes made no change 
in my strength. Insomnia was the greatest annoyance suffered while con- 
fined to the house. Three or four hours' sleep was all that could be 
obtained. The loss of sleep did not, however, leave me unrefreshed. 

" Treatment : From January 12th fantdism to the muscles every day until 
February 15th, afterwards three times a week for three weeks. Tincture 
of mix vomica and tincture of phosphoric ether were given for ten days. 
Tin- stomach rejecting these, one-thirtieth of a grain of strychnine was 
substituted, which was increased to one-fifteenth three times daily for six 
weeks. A pint of ale daily for two months. Friction and kneading of 
muscles every morning for one hour." 

Causes. — Morbid Anatomy and Pathology. — Dowse 1 quotes 

Balthazar Foster, who has stated that "he has uever known paralysis to 
follow the non-febrile form of diphtheria." Dowse thinks that the vio- 
lence of diphtheria has little to do with the development of the paralysis, 
and says that he has Been cases following modmed attacks. 

M \ own experience leads me to disagree with him. I have seen six 
of diphtheritic paralysis, and these were among the most \i<>lent 

_. 

1 s«-.. r.-i- ( - reported by Dr. A. \Y. Foot, Dublin Quarterly Journal, Sept. 
1872, ]». 176, of "Locomotor Ataxia subsequent t<> Diphtheria." This was evi- 
dently tii'- ataxic form of Brenner. 



DIPHTHERITIC PARALYSIS. 4G0 

Labadie Lagrave, Andral, and others have called attention to the blood- 
changes in tlii> disease, viz., diminished fibrine and an increased Dumber 
of white corpuscles. Saune lias found that the red corpuscles are de- 
stroyed, and that there is a great increase in the amount of de*bris with 
albuminous urine. The paralysis takes place, however, in a later stage, 
but Dowse lias shown that the albumen in the urine reappears with tie- 
paralysis, and that it again diminishes in quantity as recovery takes place ; 
hence we may infer that a connection exists between the blood condition 
and the paralysis. I am inclined to think that the paralysis of the palate and 
muscles of the pharynx are the result of pressure made by the diphtheritic 
membrane. 

Diagnosis. — Diphtheritic paralysis need not be mistaken for any 
Other affection, though occasionally, in its ataxic form, it is confounded 
with posterior spinal sclerosis. Its transitory nature should render such 
an error as this impossible. For the same reason it should not be con- 
fused with organic paralysis. , 

Prognosis I have never heard of a fatal ease, that is. a death which 

was a result of paralysis occurring during convalescence from diphtheria. 
When paralysis takes place before the violence of the disease has been 
spent, death may take place from the acute disease. The duration of the 
paralysis is from eight or ten days to many months. 

Treatment. — Nutritious food, massage, strychnia, and iron, quinine, 
and stimulants with faradization, are the indications. The plan pursued 
in Dr. Reed's case will serve as a model. 



470 DISEASES OF THE PERIPHERAL NERVES. 



CHAPTEE XVIII. 

DISEASES OF THE PERIPHERAL NERVES (Concluded). 

LEAD POISONING. 

Synonyms Colica pictonum ; Plumbism. 

The toxic effects of lead, whether taken internally or absorbed by the 
skin, are extremely varied and interesting. Disorders of motility and 
sensation arc produced which, though rarely alarming, are most distress- 
ing conditions. 

Symptoms. — Among the early symptoms of lead poisoning may be 
mentioned the abdominal pain which has received the name of colica 
pictonum, and which Romberg 1 considers a species of neuralgia of the 
mesenteric plexuses. Tanquerel 2 has graphically sketched the appearance 
and development of this symptom. At first there is constipation which 
lasts for some weeks, and sometimes follows a slight diarrhoea, while after 
a short time a sense of epigastric oppression is experienced, with nausea 
and (-nictations, and gnawing twisting pains which occupy the umbilical 
region. These pains are much worse at night, and rarely shift their posi- 
tion. Pressure relieves them to some extent, as it does in simple colic. 

During the paroxysms there is great muscular rigidity, and the ab- 
dominal muscles seem to be rigid. The skin is cool, and perhaps bathed 
in Bweat, and the pulse is full and bounding, and quite hard. The con- 
stipation continues, and the U-c('< that are occasionally voided arc scyba- 
lous and of a whitish-gray color. The urine is of high specific gravity, is 
quite Lighl in color, and voided in considerable amounts. 

The complexion of the individual is sallow, and tin' skin rough ; and, if 
hi- lips he separated, the peculiar bluish line at that part of the gums 
which [s in contact with the teeth will be seen. This line is a quite COn- 

stanl symptom; it is perhaps one of the most valuable diagnostic marks. 
Tie- remaining part of the gums is quite spongy and dark. 

There may be in conjunction with lead colic a very well-marked cuta- 
neous anaesthesia or hyperesthesia, hut the latter is more common. The 

-kin is exquisitely Bensitive in parts, such as the scalp, the groin, the bend 
of tin- elbow, and other like regions. Pressure seems to relieve this ten- 

derness, but light irritation aggravates it markedly. 

A form of tremor which is apt to he eonfused with those of a selenitic 

nature has been found as ;i ran- symptom. Brockman observed it among 

1 Op. cit.. vol. ii. p 182. 

2 Traitls dea Maladiee <!<• Plomb. <>n Saturnines, L839. 



LEAD POTSONING. 471 

workers in the lead mines of the Hartz Mountains. It may be local or 
general, and in the first form the hands are affected. The lips may be 

agitated, and the levator anguli oris is often involved, so that the corner of 
the mouth is drawn up. In the other form the head, trunk, and ami- n it- 
all in a state of tremor, the head being bowed on the chest, and the legs 
unsteady. In this latter form there is usually a profound toxic condition. 

By far the most important symptom, and one which may or may not be 
preceded by lead colic, is the form of local paralysis known as " lead palsy" 
or " lead paresis." The onset of the malady is usually gradual, the patient 
being unable at first to extend the fingers. There is nearly always sonic 
numbness of the hand, and rarely tremor. It is not often that the para- 
lysis becomes general, but the extensors of the forearms are, as a rule 
involved. In this condition the hands hang helplessly, and an appearance 
results which has been called " drop wrist." There is generally some 
paralysis of the flexors, but this is almost inappreciable. Other muscles, 
notably those of the shoulder, are affected if the lead saturation be pro- 
found, and, as a consequence, the patient may be unable to raise his arm. 
I have never seen a case in which the lower extremities were involved. 

Electric sensibility and contractility are much reduced, and there is 
marked anaesthesia in most of the cases. Faradism rarely provokes mus- 
cular contractions, and in old cases even the galvanic current fails to call 
forth the slightest response. 

Atrophy is a result of the paralysis, and the interosseous spaces of the 
forearm are sometimes very plainly marked, the loss of substance being 
quite decided. 

The colic generally subsides with the appearance of the paralysis, and 
according to Romberg 1 the two conditions rarely coexist. In the cases 
recorded by various observers the muscles of both extremities of one kind 
were affected in the great majority of instances, and from my own expe- 
rience I consider unilateral lead paralysis to be an anomalous condition. 

Occasionally a cerebral condition results from lead poisoning, and gene- 
rally follows the colic. This is characterized by vertigo and headache. 
general malaise, and tremor of the hands which is aggravated by volun- 
tary action. A more serious state is sometimes produced, however, which 
is symptomatized by delirium, convulsions, and stupor. 

The duration of lead paralysis, or the other condition I have noticed, is 
of course governed by the existence of the cause and the exposure of the 
patient. Most of the toxic lead states disappear, however, in a very short 
time, provided the patient protects himself by leaving his injurious occu- 
pation, and the proper remedies be administered. 

The following may be cited as a well-marked case of lead poisoning: — 

Jas. McK., ret. 55, N. Y. City, painter, lias followed his trade ■* > .'» years, 

engaged mostly on " inside work," ••flatting." Never had nnv trouble 
till two years ago, when he noticed pains in his limbs, back, and Bubocci- 



1 ()[). oit., vol. ii. p. 136. 



472 



DISEASES OF THE PERIPHERAL NERVES. 






pital region ; not much colic, but some nausea; loss of appetite ; not con- 
stipated. While actually engaged in work lie became dizzy, and " a blur 
came across his eyes." Last acute attack was obliged to leave work sud- 
denly on account of severe backache. He then noticed a loss of power in 
right hand. He consulted me in July, 1877, presenting well-marked 
•• wrist drop," BO that he was unable to extend his hand. He complained 
of formication of soles of feet, insomnia, and pains in shoulders, knee- 
joints, and about heart. Well-marked blue line and very dirty gums. 
The necks of the teeth are carious and black, and he has lost several of 
them during the past few years. 

Loss of sensation of cutaneous surface. 

Hand? — Atrophy of adductor of thumb, so that quite a hollow exists. 

Forearm. — Complete loss of electro-muscular contractility in common 
extensor of right forearm; slight power under electrical stimulus of ex- 
tensor of thumb and little finger. Flexors slightly impaired, but con- 
tractility scarcely lost. 

Arm Muscles all contract well. Patient cannot take off bis coat or 

underclothing, or cannot button his clothes. 

Treatment Electricity and potass, iodid. with strychnine. 

Causes. — The majority of cases of lead poisoning arise from the inspi- 
ration of finely divided particles of lead, and not from the manipulation of 
pieces of the metal; consequently, painters, smelters, white-lead makers, 
and miners are more often victims than any other classes of individuals. 
There seems to be an idea that printers are especially subject to lead dis- 
eases ; and at the request of the Board of Health of the city of New York 
I made an extensive examination of the printing-offices for the purpose 
of testing the question. I interviewed nearly 1500 men, women, and 
children, and found not a single case of paralysis. Among the grinders 
of type (those who smooth the sides and ends of the type against large 
rough stones), I found that the persistent use of the muscles of the thumb 
and forefinger, in one case, resulted in a Condition resembling progressive 
muscular atrophy. In the lead pipe and shot manufactories my experience 
was the same. 

The painters, however, seem to be most frequently poisoned. An ope- 
ration known as "flatting," in which the painter closes all the doors 
and windows of a room, and applies thin paint, is attended with great 
danger. The turpentine evaporates rapidly, and carries with it minute 

particles of lead which the workman must inhale. 

Dr. Richardson, 1 in a thesis which embodies a large amount of valuable 
research, thus describes the manner of preparing white lead, and the dan- 
ger which attends its manufacture. 

"The metal first comes in contact with the skin of the men in being 

carried l>\ hand from the cars to the melting-room. Here many tons are 
melted al once and cast into thin, circular, perforated plates called buckles, 
of such shape as to expose as much surface as possible for the weight. 



1 < in r>ni\ force dynamometer index to I with right hand; left, 15. 

2 Graduation Thesis, Harvard Medical School Boston Med. and Surg. Journ., 
Oct. i. L877. 



LEAD POISONING. 473 

The temperature is very high. Bathed in perspiration the men stand for 
hours inhaling the minute particles of the oxide of lead which '-cape 
from the cooling buckles and fill the air. Their thirst in this pari of the 
process is insatiable, and enormous quantities of ice-water are -wallowed, 
whereby the dust, which adheres to the tongue and lips, is washed directly 
into the stomach. 

Having been carried to a neighboring shed, the buckles are placed over 
pyroligneous acid in earthen pots of about four quarts capacity. Many 
thousand of these pots are packed together in the refuse of Btahles or the 
exhausted bark from tanneries, and are exposed to the moderate heat 
which is spontaneously generated about them. The wood vinegar is vola- 
tilized and rises through the buckles, changing by some obscure chemical 
reaction the blue metallic lead into the white carbonate. After an ex- 
posure of this sort, lasting from six weeks to three months, the pots are 
unpacked and the whitened lead removed. Here for hours men breathe 
the vapors rising from the heated bark, loaded with poisonous particles of 
the now dusty metal. In English mills this part of the process is done 
by women, with most disastrous effects upon the health. To separate the 
blue from the white lead the buckles are placed in a revolving cylinder of 
wire-cloth, through which the carbonate, more or less pulverized, falls. 
The blue portion remains in the cylinder and is melted again. To be in 
this room without protection is suicidal, for the air is filled with visible 
clouds of dust. The utmost care must be taken. The mouth and nostrils 
are covered by a moist sponge to catch the floating particles. The skin 
and clothes quickly become white Avith lead. The semi-powdered metal, 
having been shovelled into barrels and rolled into another division of the 
works, is mixed with water and finely ground. "When it fills the water 
as a milky precipitate, the whole is drawn off and dried on long tables at 
a temperature of 140° F. Formerly the grinding was done without 
water, and the lead sickness was much more common than now. The 
drying-room is the most poisonous one in modern mills. It combines the 
effects of the dust which fills the air with those of a heated atmosphere. 
Here, as in the melting-room, the skin is kept in the best state tor absorp- 
tion. A terrible thirst makes the men swallow large quantities of cold 
water with the lead which accumulates on their lips and tongues, while at 
every breath fine dust is drawn into the lungs. 

The general appearance of the men i> not good. The faces are sallow 
and more or less worn. The sclerotic coat is yellowish. Their motions 
are far from energetic, and in some cases eccentric and unsteady. One 
would say immediately, I think, that the general appearance is much 
below that of the average workman. 

1. The firsl man examined has worked in all parts of the mill tor thir- 
teen years. IIi< only trouble LB rheumatism. The gums show a distinct 
blue line along the border. 

"2. After seven years in the corroding room- has no Bymptoms excepting 
the blue line. 

;i. After orindi] s lead with oil has only the blue line. 



474 DISEASES OF THE PERIPHERAL NERVES. 

4. After working in all parts of the mill for six months has had violent 
eolic and great constipation. Blue line marked. 

5. Reports only bine line after four years' work. 

6. The machinist, after repairing in the drying-room a few hours a day 
for ten days, was affected with colic and constipation. Has great habit- 
ual constipation. Blue line very marked. 

7. After seven years only blue line. 

8. After twelve years has only bine line and fungous bleeding gums, 
witli occasional colic and obstinate constipation. 

9. After six years in corroding-room has only blue line. 

1<>. Has worked in all parts of the mill for fifteen years without show- 
ing a trace of blue line or any other symptoms whatever. Very neat. 

1 1. After three years only blue line. 

] '2. After four years, nothing. 

1 •>. Bine line, rheumatic pains, and fainting fits. This was a remark- 
ably neat man. 

1 4. After four years no trace of poisoning. 

1 o. After four years entirely used up. Had to leave all work. 

1 6. After one year's work completely crippled, having paralysis of the 
extensors, aphonia, and general debility. 

1 7. The carpenter, after repairing ten days in the drying-room, had 
severe colic, obstinate constipation, and persistent blue line. 

]8_7o. Of the rest of the seventy-five men whom I examined all had a 
distinct blue line about the gums, and, with one or two exceptions, habit- 
ual constipation. There was nothing further than this to suggest the 
presence of lead. 

In addition to the above cases, three of the former employe's had suf- 
fered with difficulty in speaking, three with amaurosis, several with cere- 
bral troubles, and many with paralysis* The superintendent has observed 
that the most frequent complaint has been of swollen joints and aching 
bones. In the numerous cases of paralysis which he has seen during 
many years' service at these works, he lias noticed that the wrists have 
become much swollen before paralysis of the extensors. A curious tradi- 
tion exists among them that they cannot drink alcoholic liquors and keep 
up with their work, like laboring men in other manufactories. Several 
cases were told me of men who quickly succumbed to the influence of the 
Lead after beginning the use of strong stimulants." 

Lead is often taken into the stomach without the knowledge of the in- 
dividual, and lead pipes are a prolific source of the contamination of 
water. I bave seen three caSCS in the same family caused by tea which 

bad br-'ii made from a Bpecimen containing particles of sheet lead which 

had lined the 1»<>\. The last two or three pounds were impregnated with 
these impurities, which had settled to the bottom of the chest. It was 

the custom t<> make t<';i and from time to time to add fresh Leaves and pour 
on hot water, bo thai there was constantly a. quantity of Lead subjected to 

the action of the fluid. Upon analysis, quite an amount of lend was 

tun, el. 



LEAD POISONING. 475 

Cases arising from the use of cosmetics and hair-dyes are too common 
to need anything more than bare mention. 

Morbid Anatomy and Pathology — Andral and Tanquerel 1 wen- 
unable to discover any pathognomonic condition of the Intestines in lead 

colic ; but the latter authority found lead deposits in the intestines, mus- 
cles, and nervous substances. In a case of lead paralysis reported by 

Gombault, 2 there was found to be no change in the cord, and the only 
morbid appearances anywhere else were in the nerves, the medullary bud- 
stance having undergone a granular alteration. No other appearances 
which might clear up the pathology of the affection have been seen. 

Remak 3 is of the opinion that lead palsy is a central disease, and he 
presents several cases to show its likeness to infantile paralysis. The 
same electrical reaction of the muscles in these two affections, and the 
fact that groups of muscles are affected which act together, not necessarily 
being those supplied by the same nerve, lead him to think that the paraly- 
sis is of central origin. The blue line of the gums, which indicate plum- 
bic saturation, was first described by Burton in 1840. By Tanquerel it 
is supposed to be produced by the decomposition of food about the teeth, 
the sulphuretted hydrogen uniting with the lead. It occurs in people who 
brush their teeth as well, however, as in those of careless and untidy 
habits. Dr. Richardson 4 tried the following experiment: — 

"A strong, healthy cat was fed for a week upon milk, to which had 
been added a small portion of a solution of plumbic acetate. At the end 
of a week the animal was killed, after having shown symptoms of severe 
constitutional disturbance. The lower jaw was excised, and the gums 
found perfectly clean. The upper jaw was also clean. The lower jaw 
was placed in water, through which a stream of sulphuretted hydrogen 
was passed for several hours. At the end of that time a perfectly distinct 
and unmistakable blue line was found throughout the juncture of the gum 
with the teeth. The stomach and intestines of the animal showed nothing 
remarkable. The presence of the blue line seems, therefore, to depend 
on a certain amount of putrefaction about the teeth." 

The elimination of lead is usually rapid when the proper remedies are 
administered to convert it into a form for excretion. If nature is left 
to herself, the process is more slow. Potain considers that it is eliminated 
only very slowly by the sweat-glands, and not by the kidneys or salivary 
glands, but I am disposed to consider that elimination does take place by 
the kidneys. 

Diagnosis — In nearly all cases of lead poisoning, it is usually possi- 
ble to detect the cachexia, which is so well expressed by the different 
signs I have enumerated. If our suspicions are not verified by appear- 
ances in an acute case, W6 may tot the patient's urine. A few drops of 

1 Tanquerel, p. 826. 2 Aivhiv. Generates, is:;;. 

■ Aivhi\ fur Psychiatric and Nervenkrankheiten, \i. p. l. 

4 Op. cit. 



470 DISEASES OF THE PERIPHERAL NERVES. 

a solution of sulphide of potassium will usually precipitate any lead that 
may be present in the form of a black sulphide. 

The paralysis may be sometimes confounded with other forms, but when 
it is remembered that the extensors are prominently affected, and that 
there are lead symptoms at some time or other, it is not possible to be mis- 
taken. 

Dr. Wharton Sinkler, 1 in an admirable paper, calls attention to the 
resemblance between "wrist drop" due to lead poisoning, and paralysis of 
the extensors from injury of the musculo-spiral nerve. He has found 
paralysis of the flexors of the forearm after injury of the nerve, and he is 
inclined to think that in the beginning there is never paralysis of the 
flexors in lead palsy. 

Prognosis With the disappearance of the cause, we may expect in 

most cases a, rapid subsidence of symptoms. It is true the paralysis often 
lasts tor some time, but even this ultimately disappears. Deaths by lead 
poisoning are rare, and I suppose when they occur are due to an affection 
of the brain, (o which I have alluded. The mortality from lead poisoning 
in New York City from 18r>2 to 1873 was 288. 48 died in 1852; and, 
strange to say, but four in 1872. 9 

Treatment If we have correctly diagnosed the condition, our ob- 
ject- must be : 1. To relieve pain; 2. To favor elimination of the lead ; 
3. To guard our patient against being continually affected ; -!. To restore 
the paralyzed limbs. 

1. No better remedy is possessed than iodide of potassium, which forms 
an iodide of lead which is an innocuous salt. This drug must be given in 
moderate doses,' 5 and its elimination hastened by mild purgatives. It will 
be found that, if the patient is obliged to continue at his work, small doses 
taken daily, or acidulated drinks, will, in some measure, prevent the ab- 
sorption of lead. If there be colic, the hypodermic use of morphine will 
give great relief. 

It has been found that those workmen who drink a great deal of milk 
seem t<> escape the danger of lead-poisoning. In France the workmen iii 
the lead-works are obliged to drink milk, and it is found to be an excellent 
prophylactic. Richardson's case (loc. cit.) did not suffer so long as he kept 
hi- COWS; but when he parted with these animals, and stopped drinking 
milk, the most decided symptoms of plumbism manifested themselves. 

A- i<> the employment of electricity, it is well to use the Paradic current 
if possible; but in some cases this produces no contractions. In such 

an event we may begin with the slowly intermitted galvanic current ; and, 
after a while, it will be found, as in some other paralyses, that the faradie 
will cause muscular response, particularly if the arm he so supported that, 

the muscles shall be relaxed. Dr. II. C. Wood,' of Philadelphia, has 

: Am. Psych, .[minimi. Nov. 1875, p. 81. 

porl of the \'»>:uA of Health, L872. 
1 \ '. i \ large dosei seem t<> increase the symptoms. 
* Phila. Bled. Times, Feb. 20, 1875. 



LEAD POISONING. 477 

noticed the fact that voluntary power may return to a great decree without 
a corresponding return of electric contractility. 

I have before alluded to an instrument devised by Dr. J. Van Bibber, 1 
and it is well to apply this so that the muscles may be entirely supported. 

In conclusion, I may present the records of a representative case of 
lead palsy. The patient was under the care of Dr. Cross, through whose 
kindness I had the opportunity of seeing him: — 

M. C., 2 aged 32 years, single, born in Ireland, a painter by occupation. 
He has been moderately temperate in his habits, and has always enjoyed 
good health until 1863, when he was suddenly seized with a severe attack 
of colic, which was preceded by great constipation of the bowel- and Loss 
of appetite. There soon succeeded nausea and vomiting of bile, accom- 
panied by an acute lancinating pain in the epigastric region, which v. 
severe that the patient was obliged to lie flat on the floor and press his 
abdomen strongly against that surface, in order to obtain temporary relief. 



1 •• After many attempts to secure this advantage by means of strips of plaster, 
it was determined to try the India-rubber muscle a- used by Dr. Lewis A. Sayre 
in orthopedic surgery. The great difficulty in the use of such an appliance was 
to etfect its application without causing injurious pressure upon the circulation of 
the arm and hand. I am not aware that these elastic tubes have been used before 
to correct this deformity, or attached by a method so simple and so free from 
pressure as that which I shall now describe. Two bands of inelastic webbing, 
pierced by eyelets at certain points, and each having a convenient buckle, serve 
as points of attachment. The one for the hand, about three-quarters of an inch 
wide, so made, that the free end placed upon the palm pointing toward the the- 
nar eminence, and the eyelet-hole resting on the ball of little linger, the band 
folded once around that ringer and passed over dorsum of the hand, the buckle 
would come in a convenient place upon the palmar surface. The band tor the 
arm about one inch in width, so arranged that the eyelet being placed upon a 
line a little above the external condyle, the buckle would rest upon the internal 
surface of the arm. 

A- -ecu in the illustration, two transverse strips of plaster are adjusted to the 
arm >o as to form an angle just below the eyelet, and thus relieve the band, which 
should be buckled loosely, from all injurious traction. The fold around the little 
finger, and the muscle resting upon the webbing on the dorsum of the hand, 
enable us to buckle the band loose enough to insure perfect abduction of all the 
fingers. Finally, a piece of India-rubber tubing of correct length and medium 
elasticity, with one of Dr. Sayre's metallic hooks attached at each end. consti- 
tutes the entire apparatus. 

Looking upon this artificial muscle as performing to some extent the duty ot % 
those paralyzed, 1 can probably best describe its application by saying, in ana- 
tomical language, that it arises from a point a little above the external condyle, 
and passing downward on the extensor surface o\' forearm, under the cutf. which 
we might call the annular ligament, forward over dorsal aspect ot' the hand, pa— - 
ing between the index and second linger-, which serve as a trochlea or pulley, 
then transversely across the palmar surface of the hand, and is inserted at a point 
about the articulation of the fifth metacarpal bone with its first phalange." — A". 
)'. Med. Journ.) May. is:4. 

2 Reported in the Psychological Journal. Jan. 1871, by l>r. Cr< ss. 



478 DISEASES OF THE PERIPHERAL NERVES. 

These symptoms continued off and on for a period of about two weeks, 
gradually diminishing in severity, however, especially after an evacuation 
from the rectum, which was only obtained with the greatest difficulty. 
His right leg at this time became (edematous. In the course of two months 
he resumed his usual avocation, that of a painter, but was not aware at 
this time that his sickness had been caused by the action of lead. During 
the year 1867 his bowels again became very costive; and his stools, which 
consisted of only a few lumps of dry, hardened feces, were attended with 
much straining. 

Soon there followed a second attack much more severe than the first, 
which was characterized by nearly similar symptoms, only there was 
superadded great tenderness over the kidneys, which were so sensitive 
that the least pressure caused him the most intense agony. The urine 
was very scanty and high-colored, and there was a well-marked blue 
discoloration of the gums. In a few months, having somewhat recovered, 
lie went to work again at his former occupation, which he pursued unin- 
terruptedly until the 25th of December, 18G9, when, after having passed 
a very uncomfortable day, his former symptoms returned with increased 
violence, while the paroxysms of the colic came on at much shorter inter- 
vals than they had done in the preceding seizures; in fact, instead of 
intermissions as formerly, there were only remissions of the intestinal 
Bpasm. For the first time he had pains in the feet and the inside of the 
thighs. The urine was more scanty and higher colored, and the bowels 
more constipated than before. 

In three weeks he again began to work, and had no more trouble, 
except constipation of the bowels and weakness in both his upper and 
lower extremities, until July, 1870, when he lost his appetite, and felt 
very weary and exhausted after any small amount of exertion. He was 
very restless and could not sleep at night, and this inability to sleep was 
a sequela of all the other seizures. Now came great tremor of the right 
hand and arm. which was soon followed by tremor in the left. 

In August, 1*70, he had his fourth and last attack, which was the most 
severe of all, and lasted about two wee&s. This time he vomited blood, 
had acute pains in the soles of his feet, and cramps in the right hand. On 
recovering from the effects of the colic he found that he was unable to use 
his arm or hand at all, and that lie had lost power in his legs also. 

Soon after this he was admitted to the Charity Hospital, where he 
remained for a fortnight, and (lining his residence in that institution he 
became delirious, and continued so for about eighteen hours. He came 
to the out-door department of the New York State Hospital for Diseases 
of the NervOUS System, September 12, 1«7<>, when his condition was as 
follows: There was the characteristic drooping of both wrists, which was 

\«i\ extreme in degree. The paralysis of the supinator and extensor 

muscles of both upper extremities was exceedingly well marked; the 
flexors were also involved, only to a much more limited extent. The 

paralysis was more considerable in the right forearm and hand than in the 
left. There was much atrophy of all the muscles of these parts, and this 
was \<r\ conspicuous in the abductors and adductors of the thumbs. The 

patienl was so very weak in his- lower extremities that he was unable to 
arise from the Bitting posture£Withoul assistance, and as he walked he tot- 
tered :ii even Step. Yet he did not drag the toe of either fool, nor swing 

his legs, as do those Buffering from hemiplegia. The blue line was very 

plainly Been .noun. I the edge Of the gums of the upper and lower jaws. 






FUNCTIONAL SPASM. 479 

On testing the amount of muscular power in the right hand by means of 
the dynamometer, he was able to turn the indicator only 10 degrees, 
while with the left he could accomplish somewhat more. The tactile 
sensibility and the sensibility to the electric current and to pain were \<iy 
greatly diminished. The temperature was also diminished; muscular 
contractility was so much impaired that a powerful induced current had 
not the slightest effect in causing contractions, and, even when the 
primary galvanic current (sixty cells and very strong) was used, the 
muscles responded very feebly, if we except, perhaps, the flexors, so 
almost completely had their irritability been destroyed. The bowd- were 
regular, the urine was normal, and, although no chemical analysis for 
lead was made, undoubtedly it would have been found. " The appear- 
ance of the patient was anaemic, cachectic, and depressed ; the breath 
was very offensive ; the retinae were anaemic ; the lungs were healthy, and 
so was the heart, excepting an inorganic murmur at its base." 

The treatment in this case has consisted of the internal administration 
of the iodide of potassium, commencing with ten-grain doses three times a 
day, and the daily application of the primary galvanic current to the 
paralyzed muscles, with a hypodermic injection of the thirty-second of a 
grain of the sulphate of strychnia every day. 

September 17. The iodide was increased to fifteen grains three times 
a day. 

2±th. Slight fibrillary contractions in the right arm were produced 
to-day for the first time by means of the faradic current. 

October 1. The iodide of potassium was increased to twenty grains 
three times a day. 

i)th. The induced current had just commenced to cause slight contrac- 
tions in the left forearm. 

November 15. Faradization of the left forearm produced good con- 
tractions in the extensor carpi radialis and ulnaris muscles. The blue 
line having disappeared, the iodide of potassium was discontinued, and a 
tonic substituted. 

23d. The muscles of both arms respond feebly to the induced current, 
yet by means of it the hands can now be extended nearly on a level with 
the forearms. The right has improved the most. Sensibility to touch 
and to electricity has much improved. His bowels are regular, he Bleeps 
well, and his appetite is good. The power in both hands is much in- 
creased, and he is able to work every day. 

January 1, 1871. The patient has almost entirely recovered. 



FUNCTIONAL SPASM. 

Under this head I propose to include the various forms of hyperkinesia 
which depend upon irritability of the nervous centre-, and which have been 
specially considered, as Tetany, spasm with voluntary movements, Reflex 
Spasm, Torticollis, Professional Cramp, etc. 

These are generally due to some peripheral cause, or may result from 
overtraining of the automatic sense, or in certain conditions arise in a 
manner which is at present not clearly understood. 



4S0 DISEASES OF THE PERIPHERAL NERVES. 



I. TETANY. 

A light form of attack arising generally from diarrhoea, cold, and con- 
stipation, and sometimes making its appearance during lactation. There 
La usually sonic formication of the palms or soles, and an awkwardness in 
the movements of the hands and feet, which is afterwards followed by a 
firm tonic contraction of the muscles of either of these parts. The flexors 
arc usually contracted, so that the hand is curved, or all the fingers closed. 
A mere decided contraction may Hex the forearm on the arm. The foot 
may lie also affected, a condition of talipes resulting, or the back part of 
the leg may be brought in apposition to the thigh. In marked forms the 
upper and lower extremities are affected together, though there is no rule 
governing this, and the spasm may be bilateral or unilateral. The attack 
rarely lasts beyond an hour or two, and in the majority of instances relaxa- 
tion may take place in from five to ten minutes. The spasms may come 
on from time to time, being separated by greater or less intervals. They 
are entirely uncontrolled by the will, and the patient cannot open his fin- 
gers when they are thus contracted. In more severe forms the muscles of 
the trunk or face become involved. Contraction of the ocular muscles, 
laryngeal spasm, trismus, or vesical spasm are examples of more violent 
action. The spasms seem to be produced when pressure is made upon a 
nerve-trunk or muscular belly, and there is loss of tactile sensibility asso- 
ciated with neuralgic pain in the main nerve-trunk of the convulsed limb. 

Tetany differs from true tetanus from the fact that the spasms affect the 
limbs, that they are intermittent in character, and that there are intervals 
of relaxation. Petlt-mal sometimes resembles this condition, but there is 
always some loss of consciousness. 

II. FUNCTIONAL SPASM W ITU* VOLUNTARY MOVEMENTS. 

Mitchell 1 reports some cases of functional spasm, which somewhat resem- 
ble- the so-called tetany. The spasm appeared during the exercise of a 
voluntary act ; they occur with the act of laughing, chewing, and talk- 
ing, ami evidently depend upon functional derangement of muscles inner- 
vated by the firsl cervical and spinal accessory nerves. In one case the 
head was drawn hack, and the spine bowed so thai the patient was jerked 
into a -(platting posture, the gastrocnemius being finally affected. 

In other cases the spasms occurred when the individual began to walk. 
In -iill other cases there was a rhythmic*] motion when the patient 
attempted any simple voluntary action. These Weir Mitchell called 
"pendulum spasms," the number of twitches averaging L60 per minute, 
ami recurring with greal regularity. 

Bamberger 9 reports ;i case which resembled spasm of another kind, of 
which I shall presently spealfc Whenever the child was held in the stand- 

1 Am. JoUIH. Med. Sciences, Oct. 1876. 

■' Quoted l>\ Handheld , Jones, Functional NerVOUB Disorders. 



REFLEX SPASM. 481 

ing posture his legs were drawn up, and agitated by ehoreoid spasms, the 
spine and neck being twisted and contracted at the same time; but when 
lie was placed upon his back these movements ceased. 

III. REFLEX SPASM. 

Under this head may be classed a long list of local convulsive move- 
ments dependent upon a variety of causes. Sometimes there arc worms 

in the intestinal canal, and at others a condition of irritability of the geni- 
tals ; while peripheral irritations of many kinds enter into the etiology of 
the spasm. 

I may illustrate the occurrence of one form of spasm by the following 
cases : — 

I. A boy, 7 years old, seen at the request of Dr. Sayre, was well 
nourished, with rosy checks and well-rounded muscles of the upper ex- 
tremities. His morbid condition had existed from birth, and lie possi ssed 
a congenital phimosis, the prepuce being firmly fastened over the glans, 
and the preputial orifice was very small and surrounded by a rigid ring <>t' 
toughened skin. On entering the room I was struck by the extraordinary 
restlessness and activity of the child. He was lying on the bed, and his 

Fig. 53. 




Reflex Spasm from Genital Irritation. 

lower limbs were drawn up and agitated by irregular spasms. The 
arms were also convulsed, and their movements were distinctly choreic. 
When held upright the child was unable to stand, not from any paresis, 
but from the apparent loss of coordinating power, the legs becoming rigid, 
and the toes of both feet adducted, more particularly the left. The child 
Was unable to speak, but attracted the attention of those around him by 
queer sounds. 1 lis face was distorted, just as we often see it in old cho- 
reic patients, but there was no evidence of imbecility. I did not infer 
that there was any mental trouble, except a preponderance of emotional 
disturbance, the boy being very fearful that he was to be hurt. Upon 
interrogating I found that he was quiet during sleep, that his appetite 
good, and that there was no irregularity or disturbance of the functions of 

the bowels or bladder. The penis was not bo sensitive as 1 had expected 
to find it from Dr. Sayre's description of previous cases. Titillation did 

not produce immediate erection, nor any increase ot* the spasmodic move- 
ments. On taking him upon my lap the thighs and legs were immediately 
drawn up ; there was no evident pain produced by pressure on t hi' Bpine. 
31 



482 DISEASES OF THE PERIPHERAL NERVES. 

II. Rosa A., •"» years old, very pale and delicate. Like one of Dr. 
Sa\ re's rases, this child was almost asphyxiated when born, and it was 
nearly ten minutes before she Mas resuscitated. A year after birth she 
contracted scarlel fever, but no other trouble supervened. After birth it 
was noticed that there Mas want of power in the lower extremities. She 
was entirely unable to stand, and as soon as she was held in an upright 
position her legs became stiff. Her intelligence was unaffected, and she 
did not sutler pain in any part of the body. 

Present Condition. — The legs are well proportioned, and there is no 
atrophy. The temperature of either limb is not lowered, but there is 
slight hyperesthesia. When held in an upright position by her father, 
who accompanied her, the legs become rigid, the toes cross each other, 
and one foot seems inclined to cover its fellow. With this rigidity there 
arc irregular convulsive movements. There is a marked contraction of 
the sural muscles, which draw up the heels, producing a double talipes. 
When laid upon her back the thighs are flexed upon the pelvis, and this, 
her father states, is her position at night. At this time the head is drawn 
back and downwards by firm contraction of the trapezius and other mus- 
cles of the neck. An examination of the genitals disclosed a very large 
cyanotic clitoris, which was quite erect. There was no history of worms. 
Unfortunately, for it was a dispensary case, the father would not allow 
anything to be done in the way of surgical interference. 

A form of reflex spasm of the eyelids was reported by Von Graefe, 1 
which rendered the patient helpless, for he was unable to go about alone. 
There was no pain produced on pressure in the course of the fifth nerve; 
but when pressure was made on the glosso- palatine arch on the left lower 
jaw, the spasm ceased at once, and the patient could open his eyes. A 
putrid ulcer was found at this locality, which acted as a centre of irritation 
upon the gustatory nerve. 

IV. FACIAL SPASM WITHOUT PAIN. 

A form of facial spasm not connected with voluntary motorial move- 
menl i> occasionally met with, the orbicularis palpebrarum or buccinator 
being affected alone, or all the muscles of the face supplied by the portio 
dura being convulsed. The trouble differs from epileptiform lie for the 
reason thai it is unaccompanied by pain. I have been so fortunate as to 

see two of these cases. One was thai of a gentleman aged .">(;, who suffered 
an almosl constant spasm of the orbicularis of the eye, which was always 
increased when he was fatigued. The eye would become red, and there 
was usuall} a discharge of tears, which were unable to find their way into 
the Lachrymal duct, and consequently ran on the cheek. A case pre- 
sented al ih<- American Neurological Society by Dr. Hammond Buffered 
from \iolent unilateral spasm of all the muscles of the face, which came on 
ever} two or three minutes. 



1 Schmidt's Jahrbuch., v«»l. I j 7 . p. 80; reported by II. Jones, p. :(!»<>. 






TORTICOLLIS. 483 



V. TORTICOLLIS. 



The sterno-cleido-mastoid muscle may be the seal of a spasmodic con- 
traction. This condition may be preceded by peripheral trouble, such as 
dentition, which was the cause in one of Romberg's cases, or by Bucb gen- 
eral diseases as rheumatism. One case, which was seen by Dr. White 
and myself, was preceded by chorea, and another, that I saw ;it the New- 
York State Hospital for Diseases of the Nervous System, was due to general 
anaemia. In both these cases, as well as in others I have observed, the head 
was bent forward and the chin pulled downward. In one case, that of the 
elderly woman seen at the nervous hospital, the spasms were intermittent. 
Radcliffe reports a case which somewhat resembles this. The muscles 
of the neck were tender and the seat of soreness, and the movements 
were attended by pain. The spasms are usually increased by emotional 
excitement, but subside during sleep. The notes of my case are the fol- 
lowing: — 

M. A. A., aged 56, U. S. Came to the hospital Oct. 20, 1872. Her 
present trouble began five years ago in a very gradual manner. There are 
now marked clonic spasms of the muscles of the anterior part of the left 
side of the neck. With their intermitting contraction, there is some pain 
at the lower insertion of the sterno-cleido-mastoideus muscle ; the trapezius 
is also the seat of spasmodic contraction. There is headache, and pain at 
the upper part of the cord. Patient's expression anxious and excited. 
Galvanism to muscles and spine, and zinci phosphidi gr. ^ t. i. d. Pa- 
tient complains of dizziness and constipation. 

The muscles concerned in this form of disease are the sterno-cleido- 
mastoideus, complexus, trapezius, and levator anguli scapulae. 

Pathology Weir Mitchell has divided the conditions under which 

spasms of this kind may occur into three groups : — 

1. "Those in which the functional activity of a muscle or set of 
muscles gives rise at times to an exaggeration of the motion involved 
naturally, and sometimes also to a more or less spasmodic activity in 
remoter groups. 

2. " Those in which the functional action of one group results only in 
sudden and possibly in prolonged acts, tonic or clonic, in remote groups 
of muscles not implicated in the original movement. 

3. " Those in which standing or walking occasions general and disor- 
derly motions affecting the limits, trunk, face, and giving rise to a general 
and uncontrollable spasm without loss of consciousness." 

The central condition is one of great reflex irritability : certain forms 
of repeated irritation producing an activity of the motor centre which 
results in an abnormal increase in reflex susceptibility. 

Treatment Agents which lower the excitability o\' voluntary 

muscular action arc id be adopted. Of these I know of no better drug 

than gelsemium Bempervirens (F. 50), conium (F. 51), musk, assafoetida, 

or valerian (FF. 52, 58, 54). Rot. and removal of the peripheral 

irritation, should the spasm bo oi reflex origin, and the ether spray to the 



484 DISEASES OF THE PERIPHERAL NERVES. 

spine, are to be resorted to; and at the same time various measures which 
improve the individual's general condition are in order. If all of these 
drugs I have mentioned be powerless to subdue the excitable condition of 
the muscles, I prefer profound brominization, which sometimes controls 
the movements. Myotomy in torticollis has not proved itself to be a 
successful operation, and so I do not recommend it. In other conditions, 
such as adherent prepuce, an operation is the only method that promises 
a cure. Galvanism and faradism have proved successful in the hands of 
many, and their use is often attended by extremely beneficial results. The 
hypodermic injections of the alkaloids sometimes succeed when all other 
remedies fail (FF. 30, 59, GO, 61, 91, 92). 



PROFESSIONAL CRAMP. 

Synonyms Writer's cramp, Dancer's cramp, Telegrapher's cramp; 

Dyskinesie professionelle ; Melker-krampf, Schuster-krampf, Nahekrampf. 

This very interesting condition, which follows the overtraining of groups 
of muscles, is found among all who engage in occupations. which require the 
exercise of particular voluntary muscles of the upper and lower extremi- 
ties to an excessive degree. Among these individuals such protracted 
muscular action, especially when of a delicate kind, is likely to be followed 
by spasmodic movements such as would come under the first group of 
Mitchell. 

It is the first of the above varieties that at present interests us the most. 

Writer's Cramp is the form of hyperkinesis with which we are the 
most familiar, and it is difficult to fail in recognizing its true character. 
After continued and fatiguing use of the pen the hand may become at 
first tired; afterwards the patient suffers from sharp pains which run 
from the hand up the arm, while dull pains seated in the ball of the 
thumb, the dorsal aspect of the fingers, the wrist, or at the exposed por- 
tion of the ulnar nerve at the elbow, are to be found as well. His first 
intimation may be a certain tired feeling, or, as a very intelligent patient 
under my care expressed it, "Tin' first idea of my trouble came from the 
feeling that I had an arm. My mind was directed to it, and whether 
resting or at work, it felt like a clumsy pari of my body." If the indi- 
vidual carefully forms his words, or if he " writes with his fingers" — a bad 
habit which schoolboys have, and which sometimes continues through 
life — the trouble is much more probable than when lie uses his whole 
hand in guiding his pen. He may find after a while that when he 

attempts t<» write, the hand will fly upwards as the result of a Bpasm of the 
extensors and other muscles on the dorsal and ulnar side of the forearm, 

--) that it LS of tec impossible to form more than one or two words of a 

note before the t rouble begins. 

This impaired w riting powef may exist to a Lighter degree ; but when the 
individual persists in bis attempts, the convulsion is certain to take place. 
A light tonic spasm of the abductor minimi digiti may occur when the 



PROFESSIONAL CRAMP. 485 

little finger is separated from its fellows, and this is sometimes an early 
sign of the disease. He may edueate the left hand to do (lie work of the 
right, and after a while may learn to use it in a satisfactory manner ; but 
very soon this too beeomes affected, and he can write with neither hand. 
Other muscular movements are freely performed, and even some which 
closely resemble that of holding the pen. Trembling sometimes super- 
venes, while fibrillary muscular contractions are suggestive of the confirmed 
disease. As is the case in sclerosis, the disorderly movements, or the 
spasms, seem to be intensified when the patient attempts to write in the 
presence of a looker-on, and he usually makes sad work. 

The fingers, forearm, and wrist sometimes become the seat of lost 
power, and this is marked in the three first fingers of the right hand, and 
the pronators and supinators lose power. Sensation is rarely lost or 
impaired. In some cases the flexors of the hand and the small muscles 
of the thumb are so weak that the point of the pen cannot be kept in 
contact with the paper, as the extensors seem to act independently. 

The same form of cramp affects the thumbs and fingers of telegraphers, 
so that their work eventually becomes an impossibility. Onimus 1 pre- 
sents a case. A* telegraphic operator, 19 years of age, first experienced 
difficulty in making dots; " d " was made better than "u;" and it was 
found that when a line was first the dots were more easily made ; but 
letters like "h" or "p" were exceedingly difficult. 2 

Dancers' cramp has also been observed. Schultz 3 describes this form of 
disease, of which he has seen three cases. It affects the solo dancers of 
the ballet as a rule, and the history of one case was the following : — 

" The patient complained of suffering very severe pains while dancing. 
Beginning in the soles of both feet, the pains spread with increasing 
severity to the calves of the legs ; they at last became so violent that her 
feeling of security was lost, the feet seeming as if made of wood. These 
pains were accompanied with violent palpitation ; and, if she continued to 
dance, she felt faint and sometimes lost consciousness, the body becoming 
quite rigid. When the pain and palpitation were less intense, the pain 
continued after dancing, and ceased very gradually, leaving some tender- 
ness of the soles ; on attempting again to dance the suffering would recur 
again. Dr. Schultz found, from the examination of these eases, that the 
cause of the pain lay in the pas performed on the points of the feet, and is 
owing to exhaustion of the muscles which fix the metatarsus and phalanges 
of the great toe. The shoe worn by the dancer, without which the ballet 
step seems to be impossible, is made as follows : The dancing-shoe is made 
rather wide; the sole is of soft leather, and shorter than the foot, reaching 
only as far as the posterior third of the ungual phalanx of the great toe. 
The upper part, generally of satin, projects forward, and supplies the place 
of the deficient leather of the sole. This pari of the satin is worked threads, 
SO that it may not be torn. In the interior of the shoe, over the leather 
sole, is a layer of thin, lirmlv-pressed pasteboard, either extending o\ er 
the whole breadth of the anterior part, or limited to the length of the 



1 Gaz.M6d.de Paris; Chicago Journal of Mental and Nervous Diseases, July 

187f). 

2 ( u ) ( ( i) ( h; p.) •• Wiener Med. Woch. 



4S6 DISEASES OF THE PERIPHERAL NERVES. 

great toe. In the former case it is carried back, gradually narrowed as 

far as the heel. The leather sole and its covering are lined with tine kid 
leather. The heel part of the shoe is quite soft, consisting only of satin ; 
and the shoe is fastened above the ankle by narrow ribbons. Without this 
preparation the pointed step is impossible." 

I have met with the affection among violin-players, and within the past 
year have had a patient under treatment, lie had been diligently prac- 
tising a •• run," which involved the necessity of complicated movements of 
the lingers ; and it was his custom, on arising in the morning, to spend a 
half hour or so in playing the difficult passage ; and on the day of the con- 
cert he worked for several hours at the same task, but upon attempting 
to play in the evening he found it utterly impossible to do so, as his fingers 
would become rigid and refuse to obey the will. It was some months be- 
fore he could again play. 

( humus, 1 in describing a form of impaired power and consequent mus- 
cular atrophy, which he calls " professional muscular atrophy," details a 
case which resembles somewhat the form of functional disease which we 
are considering. It begins by muscular cramp, and there is subsequent 
Loss of power with wasting. I therefore think we may consider this affec- 
tion as a connecting link between scrivener's cramp and progressive mus- 
cular atrophy. He says : — 

" Recently I observed one case which it was most difficult to differentiate 
from progressive muscular atrophy, as the atrophied muscles were the same 
as those which are the first affected by this latter affection. They were 
the muscles of the thenar eminence, and chiefly the adductor pollicis. 
The patient was an enameller, who had to hold an object all day between 
his thumb and index finger. He first got cramps in the thumb, which 
suggested the idea of scrivener's palsy; then tremor of the thumb, on ac- 
count of the fibrillary contractions; a*nd, lastly, atrophy. Under the 
influence of treatment there was a rapid amendment, which showed that 
the case was really one of professional muscular atrophy, and not com- 
mencing progressive atrophy." 

Causes and Pathology This spasmodic affection follows tin 1 con- 
tinued use of the muscles which are concerned in delicate muscular actions; 
and is not only produced by writing, but, as I have shown, by other forms 
of manipulation requiring great delicacy of coordination. The higher and 

the more complex is the eharaeter of these acts, and the more easily the fac- 
ulty tO perform them becomes developed, so iniieh the greater is the danger 

of the disease. An act which requires at first mental direction of a superior 

kind, when acquired and executed unconseiously . is much more likely to 

give rise to this neurosis than one of a grosser kind, or one which is con- 
- 1 . i f 1 1 1 \ performed under the active direction of the will. For this reason 

writer's Cramp IS much more rare among those who write and meanwhile 

compose, than among clerks ur copyists who do k> machine work." Con- 
stant use of the pen (.t' this kind i- seen to be followed l>\- mischief. Such 



1 I. Ion Lancet, Jan. 22, 1876. 



PROFESSIONAL CRAMP. 487 

causes as piano-playing or violin-playing are by no means rare A young 
lady, sent to me by my friend Dr. D. M. Stimson, owed all her trouble to 
a bad habit she had contracted of reading novels while she practised her 
scales. In her case there was extensor paralysis, and some loss of sensa- 
tion, which remained after a spasmodic stage. 

The conditions then, with the exception of paralysis, are the result of 
an over-developed automatism, and are not, I am convinced, connected 
with any central change, though Mr. Solly 1 is inclined to consider that 
there is degeneration of the motor cells in the upper part of the cord. 

In writing a familiar word, or collection of words, the educated indi- 
vidual does not stop to form every letter, but the pen is unconsciously 
guided. It is even possible to talk while writing or playing the piano, and 
equally complex feats are performed while the mind is not engaged. In 
many of these acts the volition is directed in other channels, or is behind 
the muscular action. The pen travels in advance of the mind ; and should 
this state of things be so exaggerated as to become more than a phase; of 
the ordinary automatism which enters into the performance of many of the 
functions of daily life, there remains a condition of disordered and height- 
ened activity which is uncontrolled by the will, and is symptomatized by 
the spasms of which I have spoken. A more advanced condition con- 
sists in exhaustion of the motor cells at the upper part of the cord, and as 
a result we find loss of power and occasionally atrophy. Poore 2 does not 
believe in the central organic origin of the disease ; but Solly, 3 Smith, 4 and 
Hammond 5 take this view r of the case. 

Among 23 cases which I have seen, the occupation of the individuals 
was as follows : — 

Clerks . . . .14 Stenographer . . .1 

Engraver ... 1 Musicians . . . "2 

Lawyers .... 2 Type-setter . . .1 

Clergymen ... 1 Cigar-maker . . .1 

As it will be seen, the patients were all men. They were all between 
the ages of 30 and GO, but I do not believe this latter fact lias very much 
importance. 

Diagnosis Progressive muscular atrophy may be mistaken for the 

paralytic form, but when it is remembered that the paralysis precedes the 
atrophy (should such tissue-change take place), and that progressive 
muscular atrophy is rarely so limited, there is no reason why the real 
nature of the trouble should not be recognized. Neuralgia of the cervico- 
brachial variety is a common symptom, and its real significance may not 
be detected; the subsequent element of spasm, tremor, or paralysis will, 
however, remove any doubt from the mind of the observer. 

1 Surgical Experiences, London, 1865, p. 205. 

2 Practitioner, June, July, and August, 1878. 

1 Op. cit * Lancet. March --'7. 1869. 

5 Op. cit., p. 7<m». 



4SS DISEASES OF THE PERIPHERAL NERVES. 

Prognosis. — If the individual gives up the occupation which has pro- 
duced the affection, there is no reason why he should not recover, provided 
the disease has not become confirmed, and even in this form Jaccoud 1 
speaks of a rare temporary amelioration. It has been my experience that, 
if taken in hand promptly, the patient may be cured. Sixteen of these 
- were absolutely cured, and continued so as long as they refrained 
from their work. Two were improved, but upon beginning the pursuit of 
their calling had relapses. The remainder were of the paralytic variety, 
and are now under treatment. 

Treatment Rest and electricity are the means at our command. 

A galvanic current is found to be the most beneficial, and the electrodes 
should be so small as to include but one muscle at a time in the circuit. 
The current must be mild, or it will only aggravate the disease. Besides 
this application to special muscles, one pole may be placed at the nape of 
the neck, and the other to the muscles of the hand and forearm. 

.V. AW, aged 38. The patient had followed the occupation of clerk for 
several years, and had assiduously worked at his desk for many hours 
in the day. Two weeks before I saw him he noticed an impairment 
in his writing power, and this consisted in an inability to write without 
the occurrence of a convulsive contraction of the extensors of his right 
forearm, by which the pen Hew from the paper. This did not occur at 
the moment of writing, but after a few words had been finished. He tried 
to keep the hand steady by the influence of the will, but all his efforts 
were ineffectual. When lie attempted to hold the point of any small ob- 
ject. Buch as a stick or pencil, against the surface, the same spasm would 
occur. There was no wasting of the muscles, pain, or other symptom. 
I determined to try galvanism combined with manual exercise, and the 
internal application of strychnia in doses of 5 ! ¥ th of a. grain. Galvaniza- 
tion of the flexors of the forearm and of the small muscles of the hand was 
made, and, at the same time, the positive^ pole was held for a few minutes 
at the nape of the neck, lie was directed to procure the round of a chair 
with which to exercise. Galvanization was persevered in, although the 
progress was very slow. At first he could not write more than two words 
(almost illegibly) ; but as he grew better, these spasms disappeared. 

Three stance s a week kept up for a period of about three months effected 
Buch ;iu improved condition that he was finally discharged al the end of 
that time. 

Strychnia and iron, or conium (FF. 8, 9, I<>, 48, 51, 72, 82), are 

remedies which may be used in conjunction. The ether spray apparatus 

doe- great good, and J have occasionally benefited my patients by fasten- 
ing the hand in an immovable apparatus or splint. Absolute cessation of 
the particular work which gave rise to the malady is to be insisted upon, 
and no benefit will resull from any form oftreatmenl unless this command 
of t he physician ie respected. 

When the patient attempts wriXing anew lie should provide himself 
with n pen having a cork hoWer, and this may be purchased from any 

1 ()p. cit., p. 302. 



PROFESSIONAL CRAMP. 489 

good stationer. He should change his system of penmanship and acquire 
the so-called free hand style, in which the fingers are engaged only in 
holding the pen, and the other motions are performed by the muscles of 
the forearm. The attempt at " shading" the lines should not be made 
but he should endeavor to adopt the round hand and avoid "pot hooks" 
and " up and down" strokes as much as possible. 

Sea air, salt baths, and a change of habits and scene are all fraught 
with benefit. 

I do not consider tenotomy advisable except in extreme instances. 



FORMULA. 

(adult doses.) 

1. 

B. Tr. aconit. rad. 3j-5ij; 

Sodii bromidi 3iss ; 

Aquaj mentli. pip. ad §iv M. 

Sig. 5j t. i. d. 

2. 

R. Tr. digital. 5»ij ; 

Syr. papa v., 

Elixir curacoa, aa £ij — M. 
Sig. 5j at a dose. 



3. 



R. Chloral, hydrat. gj ; 
Ess. month, pip. q. s. ; 
Syr. tolutan., 
Mucil. acac, aa §ij. — M. 

Sig. 5j :it a dose, well diluted. 

1. 

R. Chloral, hydrat., 

( ialcii bromidi, aa sj ; 
Syr. Limonis Jij ; 
A.qusB ad Jiv — M. 

SiL r . r)j at a dose. 



H. Dragee ergotin (Bonjean), (gr. v.), no. \\. 
Sig. ( > i * « - ;ii :i dose. 



FORMULAE. 4'Jl 



6. 



R. Fl. ext. ergotae §ij ; 
Sodii bromidi ^i>s ; 
Aquae camphorae ad Jiv. — M. 

Sig. A teaspoonful every 4 hours. 



R. Acidi hydrocyanici dil. n^ xx-xxxvj 

Aq. ext. ergotae 3J M. 

Ft. massa et divid. in capsul. no. xij. 
Sig. One every 3 hours. 



8. 



R. Strych. sulph. gr. ss-j ; 

Cinchonas sulph. 5j 5 

Tr. ferri chlor. 5 V > 

Acidi phosph. dil., 

Syr. limonis, aa ^ij M. 

Sig. A teaspoonful in water at a dose. 

9. 
Hammond' s Solution. 

R. Strych. sulph. gr. ss— j ; 

Quiniae sulph., 

Ferri pyrophos., aa 5j > 

Acidi phos. dil., 

Syr. zingib., aa £ij M. 

Sig. A teaspoonful in water at a dose. 

10. 

R. Ext. nucis vom. gr. viij ; 

Quin. sulph. 3j ; 

Ferri redacti gr. xxx M. 

Ft. massa et divid. in pil. no. xxx. 
Sig. One after eating. 

11. 

R. Sol. Btrych. sulpli. (gr. j-jfij I .v.i 

Ferri dialysat. giss ; 

Aquae flop, aurantii ad Jiv. — M. 
Sig. A teaspoonful al a dose. 



492 FORMULAE. 



12. 



R. Ferri carbonat. sacch. 30 ; 

Cinchon. sulph. gr. xxiv. — M. 
Divid. in chart, no. xij. 



Sig. One t. i. d. 



13. 

R. Zinci oxidi 5j ; 

Confectio. rosae q. s M. 

Ft. massa et divid. in pil. no. xxx. 
Sig. One t. i. d. 

14. 

R. Sol. potass, arsenitis 30 ; 

Quiniae sidph. 3*s ; 

Acidi sulph. aromat. q. s. ; 

Aquie anisi %W M. 

Sig. A teaspoonful every 4 hours. 

15. 

R. Sol. acidi hydrobromici, 

Elixir simplicis, aa 3 i j — M. 
Sig. A teaspoonful before each meal. 

16. 

R. Quiniae sulph. 5.J ; 

Sol. acidi hydrobromici ^iij ; 

Aqu:c camphorae ad 5iv M. 

Sig. A teaspoonful three times a day, in a tumblerful 
of water. 



R. Potass, iodidl 3'j ; 

Potass, nitrat. 5 v .j ; 

Syr. sciUae .s.j ; 

S|)ls. amnion, acetat. ad ^iv I\I. 

Sig. A teaspoonful every 1 hours. 



is. 



R. Potass, acetat. 3\i ; 

[nfus. digitalis .^\ tij.— »M. 
Sig. A dessertspoonful Mirer times a day. 



FORMULAE. 403 

10. 

Payley's Pill, 

R. Pil. hydrarg. massae, 

Pulv. scillae, 

Pulv. digital., aa gr. xxiv M. 

Ft. massa et divid. in pil. no. xxiv. 

20. 

R . Hydrarg. bichlor. gr. ss ; 

Potass, iodid. 3.j ; 

Tr. cinch, co. %iv — M. 
Sig. A teaspoonful three times a day. 

21. 

R. Tr. ferri chlor., 

Tr. digitalis, aa ^ss M. 

Sig. Ten to twenty drops, in water, three times a day. 

22. 

R. Elaterii gr. iv ; 

Ext. nucis vom. gr. iij ; 

Confectio. rosa3 q. s M. 

Ft. massa et divid. in pil. no. xij. 

23. 

R. Sodii bromidi, 

Amnion, bromidi, aa £ss ; 

Chloral, hydrat. 3vj ; 

Tr. aconiti rad. 3iss ; 

Aqna3 menth. pip. ad 51V M. 

Sig. A teaspoonful three times a day, or oftener if 
required. 

24. 

R. Phosphori gr. ij ; 

01. amygdake dulc. sj ; 

Ess. month, pip. q. b. ; 

Mucil. acac. 3 V J« — M. 
Sig. A teaspoonful after eating. 



4V»4 FORMUL-iE. 

25. 

Thompson's Solution. 

R. Phosphori gr. ss-iss ; 

Alcohol absol. q. s. ut dis. ; 

Ess. men tli. pip. q. s. ; 

Glycerinae ad siv M. 

Sig. A teaspoonful after eating. 

26. 

R. Phosphori gr. ss-j ; 

Sevi gr. c — M. 
Divid. in pil. no. xxv. 
Sig. One after eating. 

27. 

R. Zinc, phosphidi gr. iv ; 

Confectio. rosre gr. xxiv M. 

Ft. massa et divid. in pil. no. xij. 
Sig. One after eating. 

28. 

R. Strych. Bulph. gr. ss-j ; 

Aeidi muriatici dil. 5 v j ; 

Aquae ad %'iv M. 

Sig. 5j t. i. d. 

29. , 

R. Strych. sulph. gr. ss-j ; 

Aeidi phosph. dil. 3'ij ; 

Syr. Bimplicis ad 5iv M. 

Sig. 5j t. i. d. 

30. 

Bartholow'a Injection for Hypodermic use, 

R. Slr\ eh. sulph. gr. ij ; 

Aq. desfcil. vel aquae cerasi 5_j M. 

81. 

R. Pepsini saech. 5 v j ; 
Aeidi umriatici dil., 
Tr. inn-is \ om.j an £ss ; 

AqilflB ciiiiiaiiioini ml t ^iv. — M. 

Sig. A teaspoonful after each meal. 



FORMULAE. 495 



32. 



R. 01. morrhua?, 

Ext. nialti (Loeflund), aa o> v - — M. 
Sig. A tablespoonful three times daily. 



R. Bismuth. Bubcarb., 

Pepsini sacch., aa §ss ; 

Pulv. aromatici ad 5*1 v. — M. 
Divid. in chart, no. xxiv. 
Sig. One t. i. d. after eating. 

34. 

R. Pepsini sacch., 

Pulv. carb. ligni. aa §sa — M. 
Divid. in chart, no. xxiv. 
Sig. One three times a day after eating. 

35. 

R. Antimon. tartrat gr. j ; 
Aquae 31 v. — M. 
If emesis is desired, give one tablespoonful every half hour till vomiting 
i> produced ; or, if continued depressing effect is desired, a teaspoonful ever}' 
hour or two. 

36. 

R. Tr. verat. virid. 3ljss; 

Aq. menth. pip. ad 5iv. — M. 
Sig. One teaspoonful every two hours, or oftener it 

needed. 

37. 

R. Phosphor! gr. j ; 

01. morrhuae Oj. — M. 
Sig. A tablespoonful at a dose. 

38. 

R. Sodii bromidi ^iss : 
Aquae camphors, 

Tr. lupulin., aa 3 i j . — M. 
Sig. A teaspoonful at a dose. 



49G FORMULA. 



39. 



R. Tr. cannabis indicae 5'j ; 

Aq. flor. aurantii ad 5 i j M. 

Sig. A teaspoonful at a dose. 



40. 

R. Ferri et amnion, citratis ^ss ; 

Tr. cinch, co., 

Tr. gentianae co., aa ^ij ; 

AqiKC ad 3 viij M. 

Sig. A ^dessertspoonful ter in die. 



41. 

R. Magnes. sulph. 5J ; 

Infus. senna? 31V ; 

Int'us. caffeae 5 i j . — M. 
Sig. A wineglassful to be taken every morning, or 
oftener if required. 



42. 

R. Syr. ferri iodid. 3vj ; 

Syr. glycyrrhizie Jiv M. 

Sig. Half to a full teaspoonful after eating. 



43. 

R. Acidi arsenici gr. j ; 

Pulv. nigr. pip., 

Ferri redacti, aa gr. xx ; 

Ext. gentianae q. s. — M. 
Ft. massa »-t divid. in pil. no. xx. 
Sig. One three times a day. 



I I. 

Ii. Ext. belladonna gr. iij-vj ; 

Zinci «»\i(li gr, xlviij ; 

S\ p, simplicis q. b. — M. 
Ft. massa et divid. in pil. no. xlviij. 
Sig. ( >!!<• thrice daily. 



FORMULAE. 4'.'T 



45. 

R. Potass, iodidi Jiss ; 

Yini Bern, colchici 5y 88 : 

Potass, nitrat. s'nj ; 

Aquae sviij. — M. 
Sig. A tablespoonful three times a day. 

4G. 

R. Sodas bicarb., 

Sulph. lot., aa 5?s. — M. 
Divid. in chart, no. xx. 
Sig. One three times a day. 

47. 

R. Croton-chloral. 3ij ss ; 
Aquae rosre §viij. — M. 
Sig. A tablespoonful at a dose. 

48. 

R. Pro t agon. 

Syr. aurantii cort.. aa 3J — M. 
Sig. Thirty drops to a teaspoonful three times a day 



40. 



R. Iodotbrmi gr. xxiv ; 

Confectio. rosa 1 q. s — M. 
Ft. massa el divid. in pil. no. xxiv. 
Sig. One thrice daily, or oftener if required. 



50. 



32 



R. Fl. ext. gelsemium semperv. 5U S> ; 
Elixir simplicis ad §iv — M. 

Sig. One to two teaspeonsfu] at a dose. 



:»1 



R. Ext. conii fl. (Squibb) §se | 

Sodii bromidi Jj ; 

Aqua- camphors ad Jiv. — M. 
Si^. Teaspoonful at a dose. 



498 FORMULA. 



52. 



R. Tr. moschi, 

Tr. lobelia?, aa 3\j ; 

Spts. etheris comp. ad 3 i j — M. 
Sig. A teaspoonful at a dose. 

53 (Tanner.) 

R. Tr. assafcetidae Jij ; 

Spts. ammon. aromatici 3iij ; 
Tinct. chiratae 3 v lj- — M. 
Sig. GO drops in a wineglassful of water every two or 
three hours. 

54. 

R. Elix. ammonia- valerianate Jiij ; 

Chloroformae 5>s ; 

Aqua? campliorae ad §iv — M. 
Sig. 5J every 3 or 4 hours. 



55. 



R. Zinci valerianat., 

Ext. hyoscyami, aa 5j — M. 
Ft. pil. no. xl. 
Sig. One at a dose. 

56. 

R. Ext. physostig. venenos. gr. xij. 
Divid. in pil. no. xxxvi. 
Sig. One every 4 hours. 

57. 

R. Syr. calci lactophosph., 
Ext. malti, aa §ij. — M. 
Sig. A teaspoonful every I lours. 



R. Ferri bronVidi 50 '- 

S\ r. LaCtucarii %iv. — .M. 
Sig. Half to one beaspoonfu] every 8 or I hours. 



FORMULAE. 499 

59. 

Hypodermic Inject! mi. 

R. Atropias sulph. gr. j ; 
Sol. Magendie gj M. 

Filter, n^v-x. 

C)0.—(BarthoIoiv.) 

R. Ext. ergotin. aq. 3j ; 

Glycerine 3J ; 

Aqua3 3vij — M. 
Filter. H],viij = gr. j. 

Gl. 

R. Atropine sulph. gr. j ; 
Aqu«e £j ; 

Acid, salicylici q. s 31. 

Filter. n l x = gr. ? V 

62. 

R. Tr. belladonnas 3ss ; 

Glycerin* §j ; 

Linim. sapon. 5iij M. 

Ft. linimentum. 

63. 

R. Tr. aconiti rad. £ij ; 

Linim. camph. comp. ad 51V M. 

Ft. linimentum. 

64. 

R. Tr. aconiti fol., 

Chloroformae, 

Tr. capsici, a a 5>s ; 

Linim. saponis ad $\v. — M. 
Ft. linimentum. 

65. 

R. Unguent, veratrire £j : 

Rad. aconiti pulv. 5.i- — M. 
I \q{ externally (with care ), 



500 FORMULAE. 

GG (TurnbuU.) 

R. Aconitiae gr. ij ; 

Spt. rectificati gtt. vj ; 

Adipis prep. 5j M. 

Kub a small part on the track of the painful nerve. 

G7. 

R. Chloral-hydrat., 

Camphorae, aa 3ij ; 

Adipis 5<s. — M. 
Use locally. 

G8 {Tanner.') 

R. Camphorae 3j ; 

Ext. belladonnas gr. iv ; 

Ext. conii gr. xlviij. — M. 
Ft. massa et divid. in pil. no. xlviij. 

Sig. One, thrice a day. 

G9. 
R. Emulsio pancreatin. 5i-o ss after cat in; 



70. 



R. Ext. belladonnas gr. iv ; 
Ext. opii, 

Ext. hyoscyami, aa gr. xij. — M. 
Ft. massa et divid. in pil. no. xij. 

Sig. One at a dose. 

71. 

R. Ext. hvoscyami, 

Ext. conii, aa gr. \\i\ . — M. 
Ft. massa el <li\ id. in pil. no .xij. 
Sig. ( me or I wq at a dose. 



72. 



R. StrychnuB sulph. gr. j ; 

" Arid phosphates" ( I [orsford), 
Tinct. cimicifugse rac., aa .^ij. — M. 
Teaspoonfu] ai a dose. 



FORMULAE. 501 



73. 



R. Syrupi phosphati comp. (calcis, ferri, etQ.). 
Sig. Teaspoonfiil at a dose. 

74. 

R. Tr. belladonnas, 

Potass, iodidi, aa 5'j ; 

Aqua; month, pip. ^i v. — M. 
Sig. 5j t. i. d. 

75. 

R. Tr. ferri perchloridi 5SS ; 

Glycerinae 3j ; 

Tr. calumbas ad jfiv. — M. 
Sig- 3J t. i. d. 

7G. 

R. Ext. belladonna? gr. iv ; 
Ext. ergotae aq. 3j 5 
Ferri sulph. exsiccat. Z,ss. — M. 

Ft. massa et divid. in capsul. no. xij. 

Sig. One every 4 hours. 

77. 

R. Argenti nitrat. gr. vj-viij ; 

Conf'ectio. rosae q. s M. 

Ft. massa et divid. in pil. no. xxiv. 

Sig. One after each meal. 

78. 

R. Argenti nitrat., 

Ext. belladonnas, aa gr. vj-viij ; 

Ext. gentianse q. s. — M. 
Divid. in pil. no. xxiv. 
Sig. One after each meal. 

70. 

R. Argenti nitrat. gr. vj-viij ; 

Ext. Qucis voin. gr. xij. — M. 
Divid. in pil, no. xxiv. 

Siff. On*' after each meal. 



502 FORMULAE. 



80. 



R. Argenti phosphat. (tribasic.) gr. viij 

Ext. quassia 1 q. s M. 

Ft. massa et divid. in pil. no. xxiv. 
Si<r. One after each meal. 



81. 



R. Ext. belladonna? gr. iv ; 

01. terebinth. Jij ; 

Buytri caeao q. s M. 

Divid. in capsul. no. xij. 



Sig. One t. i. d. 



82. 

R. Tr. physostig. venenos. n^v— x ; 

Glycerina 5.j ; 

Aq. ros;e ^iij — M. 
Si<z. At a dose. 



83. 

R. Tr. aconiti rad. TT^v ; 

Chloroform^ n^x ; 

Syr. papav. §ss. — M. 
Siff. At a dose. 



84. 



R. Amnion, bromidi, 

Sodii bromidi, aa gj — M» 

Divid. in chart, no. xlviij. Put in waxed paper. 
Sin-. Two al night, and one in the morning. 



85, 

R. Amy] nilrili ^iij ; 

Alcohol, absol. ad Jij M. 

The patient Bhould !•<• directed to^rovide himself with ;i small homoeo- 
pathic bottle, into which he is to pul 5 88 °' ,n< ' mixture. When he has 
.•in aura of sufficient length, he may quickly empty the contents of the 
bottle in his handkerchief, and apply ii to the nostrils. 



FORMULA. 503 



86. 



R. Tri-nitro. glycerini Jss ; 
Alcohol, absol. 5 v j M. 

Sig. 8-10 drops three times a day. 

87. 

R. Camphorae monobromidi 5 ss ~5j ; 

Confectio. rosae q. s M. 

Divid. in capsul. no. xij. 

Sig. One every hour until the effect is produced. 



R. Tr. cannab. Ind., 

Tr. hyoscvami, aa Jv '■> 
Tr. conii 5i ss -5 u j '■> 
Syr. lactucarii ad ^iv — M. 
Sig. Teaspoonful at dose. 

89. 

R. Tr. nucis vomicae 5 V ; 
Spts. amnion, aromatici, 
Tr. capsici, aa 3 v j ; 
Aquae camphorae ad giv M. 

Sig. Teaspoonful at a dose, in the morning. 



90. 



R. Tr. digitalis 5vj ; 

Ferri dialysat. ^j ; 

Elixir Chartreuse alb. ad 5iv M. 

Sig. 5,j t- i« d. in water. 



91 — Burmann's Hypodermic Solution. 

R. Coniae 3iij, n^xij ; 

Acidi acetic, fort. 5'ij< T7 l x ij ! 
Spts. \ ini rect. 5.i ; 

Aquae destil. ad 2jij M. 

Sig. n^v s= ny conise. Begin with one drop 



504 



FORMULAE. 



92. 

Hypodermic Injection. 

R. Daturiae gr. j ; 

Ac. acetici fort. q. s. ; 

( rlycerina? 5'j ; 

Aqu;v destil. ad £j M. 

Sig. Begin with three minims. 

93. 

R. Amnion, muriat. 31J ; 

Pulv. aromatici, 5j M. 

Divid. in chart, no. vj. 

Sig. One every hour. 

94. 

R. Pulv. paullinae sorbilis ^j. 

Divid. in chart, no. xxiv. 

Sig. One to three every hour till relieved. 



95. 



R. Fructus belladonna §iv; 

Spts. vini rect. o yil J — M- 
Ft. linimentum. 

The fresh berries should be obtained ; but, if this is impossible, the 
leaves, cither fresh or dried, in the same quantity may be used. In either 
case the liniment should not be \\>vd for several days. 



Battery Fluid (for zinc-carbon batteries). 

R. Potass, bichrom. pulv. Sviij; 
Aquae bullientis < )\ ; 

When cold, add — 

Acidi Bulph. 5 vij — M. 



INDEX 



ABSENCE of blood in cutaneous vessels 
in hysteria, 373 

of " tendon reflex" in locomotor 
ataxia, 277 
Abstinence from food in hysteria, 377 
Abuse of bromides in epilepsy, 329 
Active cerebral hyperemia, 69 
Acute alcoholism, 351 

cerebral anaemia, 113 

cerebri tis, 149 

myelitis, 233 

softening, 149 
Adult spinal paralysis, 247 
iEsthesiometer, the, 22 

Sieveking's, 22 
Affections of the organs of speech in 

chorea, 394 
Agraphia, 165 

Aitken on prognosis of softening, 161 
Alalia, 161 
Alcohol in urine, means of detecting, 358 

in ventricular fluid, 357 
Alcoholism, 351 

acute, 352 

causes of, 355 

chronic, 354 

definition of, 351 

diagnosis of, 359 

hallucination in, 353 

morbid anatomy and pathology of, 
356 

prognosis of, 358 

symptoms of, 352 

treatment of, 359 
Anaemia, cerebral, 113 

spinal, 227 
Anaesthesia, 448 

auditory, 448 

causes of, 449 

diagnosis and prognosis of, 450 

of fifth nerve, 449 

hysterical, 372 

of radial nerve, 449 

symptoms of, 448 

treatment of, 450 
Aneurism of brain, 196 

miliary, 196 
Antero-lateral amyotrophic sclerosis, 289 
causes of, 202 
diagnosis of, 298 
morbid anatomy of, 292 
prognosis of, 298 
symptoms of, 289 

synonyms of, 289 
treatment of, 293 



Antero-spinal paralysis of adults, 247 
causes of, 262 
definition of, 247 
diagnosis of, &52 
morbid anatomy and pa- 
thology of, 252 
prognosis of, 254 
symptoms of, 249 
synonyms of, 247 
treatment of, 254 
of infancy, 239 
causes of, 243 
definition of, 239 
deformities in, 239 
diagnosis of, 240 
electricity in, 240 
morbid anatomy and pa- 
thology of, 243 
muscular tissue, changes in, 

245 
prognosis of, 246 
Sinkler's case of, 239 
symptoms of, 239 
synonyms of, 239 
treatment of, 246 
Aphasia, 161 

definition of, 161 
diagnosis of, 175 
history of, 102 
infantile, 174 

location of speech centre in, 168 
Lordat on, 104 
medico-legal study of, 177 
pathology of, 107 
synonyms of, 161 
treatment of, 178 
trephining in, 179 
with left sided paralysis, 171 
without lesion, 170 
Apoplexy, 83 
Apparatus, electrical, 80 

for the treatment of nervous diseases, 

30 
Van Bibber's, 30 
Arcus senilis, the, 94 

Arrangement of nerve-roots in posterior 
columns, 285 

Arthropathies in cerebral hemorrhage, 

91 
Asemasia, 101 
Asthenic cerebral hyperemia, 89 

Atheromatous ohangeS in \ 

Athetosis, 92 

Atrophy, partial facial. 

causes of, 268 



506 



INDEX. 



Atrophy, partial facial (continued). 
diagnosis of, 2 
Draper's case of, 267 
pathology of, 268 
prognosis of, 268 
synonyms of, 266 
symptoms of, 266 
treatment of, 269 
progressive muscular, 255 

with cerebral sclerosis, 18 
Auditory vertigo, 124 
causes of, 126 
definition of, 124 
diagnosis of, 128 
pathology of, 126 
synonyms of, 124 
treatment of, 128 
Automatic man, the, 314 



BASEDOW'S disease, 412 
Basilar meningitis, 66 
Bed-sores, treatment of, 238 
Bell's paralysis, 453 
Bloodletting in apoplexy, 108 
Blue line, the, 475 
Bone changes in posterior spinal sclerosis, 

283 
Bony growths, 198 
Brain lesions. 97 
tumors, 185 

choked disk a symptom of, 188 
diagnosis of, 199 
localization of, 200 
morbid anatomy of, 189 
prognosis of, 202 
symptoms of, 185 
treatment of, 202 
varieties of, 189 
Brittleness of bones in locomotor ataxia, 

283 
Broca on location of speech centre, 168 
Brown-SeqoarcPs theory of auditory con- 
vulsions, 127 
Bulbar diseases, 3()8 
paralysis, 836 

r:ins('S Of, 339 

condition of tongue in, 337 

diagnosis of, 340 

morbid anatomy and pathology 

of, 840 
prognosis of, ; ! 12 

progressive variety of, 889 

reflex variety of, 889 
stationary variety of, 
sj mptoms of, 886 
-\ oonj ma of, '■'•'■' i '< 
treatment of, 8 \2 
Burrow os* experiments, 1 16 



C.\\< BROI B growths In brain, 190 
of oerehellnr tremor, 1 9 l 
i I beam a torn a, 12 

i,i post paralj tio ohorea, 



Case (continued). 

of spinal tumor, with persistent reflex 
sensibility, 215 
Catalepsy, 389 
causes of, 390 
definition of, 389 
diagnosis of, 391 
fiexibilitas cerea in, 389 
induced in animals, 391 
malarial, 390 
morbid anatomy and pathology of, 

391 
prognosis of, 392 
symptoms of, 389 
treatment of, 392 
Cauteries, 32 
author's, 32 
glass rod, 32 
(iluerard's, 33 
Pacquelin's, 33 
Central neuritis, 91 

spinal hemorrhage, 220 
Cerebellar hemorrhage, 112 

tumor, case of, 1 94 
Cerebral anremia, 113 
causes of, 116 
chronic, 114 
definition of, 113 
infantile, 115 
morbid anatomy and pathology 

of, 1 1 8 
prognosis of, 121 
symptoms of, 114 
synonyms of, 113 
treatment of, 121 
congestion, 72 
hemorrhage, 83 

attacks of, without loss of con- 
, sciousness, 87 

causes of, 94 
condition of eyes in, 86 
conjugate deviation of eyes in, 

86 
definition of, 83 
diagnosis of, K'O 
morbid anatomy and pathology 

of, 96 
post- paralytic states in, 91 
prodromata of, 83 
prognosis of, 104 
psychical disturbance in, 85 
residual paralysis in, 88 
respiratory disturbance in, 86 
seat of, 99 

symptoms of, 88 
time of attack of, 95 
treatment of, s: i 
hyperemia, 69 
causes of, 78 
definition of, 69 

diagnosis of, 78 

influence Of occupation in, 73 

local, 7'. I 

morbid anatomy of, 77 
pathology of, 75 



INDEX. 



507 



Cerebral hyperemia (continued). 
prognosis of, 80 
symptoms of, 70 
synonyms of, 69 
treatment of, 80 
meninges, diseases of, 35 
meningitis, acute, 44 

causes of, 45 

diagnosis of, 46 

pathology and morbid an- 
atomy of, 46 

prognosis of, 49 

symptoms of, 44 

treatment of, 40 
chronic, 65 

treatment of, 68 
pachymeningitis, 35 

acute, symptoms of, 35 
chronic, causes of, 39 

morbid anatomy and patho- 
logy of, 39 

osseous plates in, 39 

prognosis of, 39 

symptoms of, 37 

treatment of, 40 
with hsematoma, 40 

case of, 42 

causes of, 41 

formation of cysts in, 41 

morbid anatomy and pa- 
thology of, 41 

prognosis of, 44 

symptoms of, 40 

treatment of, 44 
rheumatism, 51 
sclerosis, 179 

causes of, 182 
definition of, 179 
diffused, 180 
diagnosis of, 184 
prognosis of, 184 
symptoms of, 180 
synonyms of, 179 
treatment of, 184 
softening, 148 
acute, 149 

causes of, 151 

diagnosis of, 153 

morbid anatomy and pa- 
thology of, 161 

prognosis of, 168 

symptoms of, 1 19 

treatment of, 153 
chronic, 154 

causes of, 156 

definition of, 164 

diagnosis of, 169 

morbid anatomy and pa- 
thology of, 1 57 

prognosis of, 1 60 

symptoms of, 1 6 1 

treatment of, I »'>L 
classification of, I I s 
definition of, 1 I s 
tumors, Grasset's classification of, 190 



Cerebritis, 149 
Cerebro-spinal diseases, 343 

meningitis, 843 

retraction of head in. 844 
Cerebrum and cerebellum, diseases of, GO 
Cervical pachymeningitis, 204 
Cervico- brachial neuralgia, 427 
Cervico-occipital neuralgia, 12') 
Character of the deposit in so-called 

tubercular meningitis 59 
Charcot on reduced temperature in hys- 

tero-epilepsy, 389 
Chloral-bromide treatment in epilepsy, 

333 
Choked disk, 187 
Chorea. 

adult, 398 

among school children, 400 

case of, 396 

causes of, 399 

definition of, 393 

dependent upon tapeworm, 396 

diagnosis of, 404 

embolic theory of, 403 

epidemic, 393 

ether spray in treatment of, 405 

heart lesions of, 401 

malarial, 400 

morbid anatomy and pathology of, 
401 

of pregnancy, 397 

post-paralytic, ( .»2 

prognosis of, 404 

symptoms of, 393 

synonyms of, 393 

treatment, 405 

with eczema, 399 
Chronic cerebral pachymeningitis with 
hematoma, 40 

myelitis, 236 
Clavus hystericus, 371 
Collateral circulation, 159 
Condition of organs of generation in hys- 
teria, 370 
Congestion, cerebral, 70 

spinal, 223 
Congestive pernicious fever, its resem- 
blance to cerebro spinal meningitis, 
Constriction hand, the, 286 

Contractions, fibrillary, 256 
Contractures in anterolateral sclei 
289 
in hemiplegia, '.'1 
in infantile paralysis, 2 10 
paralytio, '.'l 
Contusions and punctured wounds :i- 

causes of paralysis, 
ConTulsion as a Bymptom of brain tumor, 

186 
Convulsive cerebral congestion, 71 

Coordination. 28 I 

Corpusoles, Gluge's, 1 ">7 
Cramp, dancer's, i v i 

telegrapher's, 184 

writer's, i v i 



508 



INDEX. 



Cramp (continued). 
professional. 434 

causes of. 486 

diagnosis of, 487 

pathology of, 486 
"Crises gastriques," 281 
Cross paralysis. 81* 
Crum-I3rown's experiments, 124 
Cutaneous eruptions iu locomotor ataxia, 
278 

D\ COSTA on cerebral rheumatism, 51 
Decubitus paralysis, 462 
Delayed transmission of impressions, 236 
Delirium tremens, 352 
Depraved appetite in hysteria, 372 
Diathetic growths, 202 
Diplopia, 70 
Diseases of cerebral meninges, 35 

of cerebrum and cerebellum, 69 
Dislocation as a cause of paralysis, 461 
Division of a nerve trunk as a cause of 

paralysis, 460 
Douleureux, tic, 420 
Dreams of movement, 404 
Duration of life of hard drinkers, 358 
Dynamometer, 25 

Mathieu's, 25 

the author's, 25 

ECHOLALIA. 176 . 
Eczema with chorea, 390 
Education of right side of the brain, 178 
Electrical apparatus, 30 
Embolic theory of chorea, 403 
Embolism, 129 

of the cerebral vessels, 137 
causes of, 141 
diagnosis of, 142 
morbid anatomy and pa- 
thology of, 1 4"> 
prognosis of, 147 
s\ mptoms of, 138 
treatment of, 147 
Emprosthotonos, 2'.Hi 
Rndemio tetanus, 299 
Epidemic chorea, 303 
Epilepsy, 808 

aborted. 818 

abuse of bromides in, 829 

age in causation of, 8 1 6 

auditory, '■'•- 1 

Brown-8equard'a experiments in, 320 

• ■- of, 816 
chloral bromide treatment of, :):;:; 
definition of, 808 
diagnosis of. 825 
dislocation <■! bones in. •" 12 
experimental production <>t, 82 1* 
grave attacks of, 809 + 

bei i 'lit y in, :: 1 7 
history of 

- i 
induration of corn us ammonis, ">l!» 
irregular attacks of, 8 1 8 



Epilepsy (continued). 
Jacksou on, 322 
light attacks of, 312 
masked, 315 
morbid anatomy and pathology of, 

318 
nocturnal, 311 
prognosis of, 325 
resembling hydrophobia, 369 
responsibility in, 315 
symptoms of, 309 
synonyms of, 308 
syphilitic, 325 

temperature influences in, 317 
treatment of, 326 
warnings in, 309 
Epileptiform tic, 425 
Equilibrium, sense of, the, 124 
Ergot in pachymeningitis, 212 
Eruptions with neuralgia, 420 
Essential paralysis, 239 
Etat crible, the, 78 
Examination of patient, 17 

post-mortem, 18 
Exhaustion simulating acute tubercular 

meningitis, 64 
Exopthalmic goitre, 412 
causes of, 417 
definition of, 412 
diagnosis of, 41 7 
morbid anatomy and pathology 

of, 417 
prognosis of, 417 
symptoms of, 412 
syni nyins of, 412 
treatment of, 418 
unilateral, 414 
Kxperimental production of epilepsy, 321 
Extravasation of blood in neuralgia, 421 

I RACIAL neuralgia, 421 
paralysis, 455 

causes of, 454 
diagnosis of. 457 
electricity in, 4o8 
pathology of, 4-">(> 
prognosis of, -157 
symptoms of, 453 
synonyms of, 453 
treatment of, 458 
wire hook in treatment of, 458 
spasm without pain, is.: 
Faradio apparatus, :s I 
Fatty degeneration of muscles, 261 
Fibrillary contractions, 256 
Flexibilitas oerea, 889 
Formulas, 400 

Functional locomotor ataxia, 281 
spasm, 479 

/ 1ALVANIC batteries, :;i 

Vl Qibney on traumatic causation of 

spinal irritation, 226 
class rod cautery, 82 

(Jliomala of brain, 19 1 



INDEX. 



509 



Globus hystericus, the, 377 

Gluge's corpuscles, 157 

Goitre, exopthalmic, 412 

Grasset's classification of brain tumors, 

190 
Graves' disease, 412 
Griffin on spinal irritation, 227 

HAMMOND on gait in lateral sclerosis, 
294 
Hardening fluids, 20 
Hemiplegia, 88 

hysterical, 375 
Hemorrhage, cerebral, 83 

meningeal, 40 

spinal, 218 
Herbert Major on structure of insula, 

173 
High temperature in tetanus, 296 
Hints in regard to methods of examina- 
tion and study, 17 
Holland on anal leeching, 47 
Hydrobromic acid, 80 
Hydrocephaloid, 113 
Hydrophobia, 3(51 

causes of, 366 

curare in, 309 

diagnosis of, 368 

Dr. Hadden's case of, 362 

morbid anatomy and pathology of, 
367 

prognosis of, 369 

symptoms of. 361 

synonyms of, 361 

treatment of, 369 
Hysteria, 370 

causes of, 378 

definition of, 370 

diagnosis of, 382 

morbid anatomy and pathology of, 
381 

prognosis of, 382 

symptoms of, 370 

treatment of, 382 
Hysterical anesthesia, 372 

arthropathies, 371 

eye troubles, 373 

hemiplegia, 375 

locomotor ataxia, 281 

paraplegia, 375 

tremor, 375 
Hystero-epilepsy, 384 

cases of, 385 

symptoms of, 385 

INFANTILE hemiplegia, 174 
paralysis, -■';'.' 
Inflammation of spinal cord, 233 
Instruments used tor the diagnosis of 

nervous diseases, 22 
Intra-vesical troubles in myelitis. 

JACKSON on epilepsy, 829 



LATERAL sclerosis of the spinal cord, 
diagnosis of, 2 
morbid anatomy of, l l 

symptoms of, . 
synonyms of, - 
t rent men t of, - 6 
Lead poisoning, 470 

causes of, 472 

diagnosis of, 475 

from tea drinking, 474 

morbid anatomy and pathology 

of, 17". 
prognosis of, 470 
synonyms of, 470 
treatment of, 476 
Local paralysis, 453 
Localization of tumors, 200 
Locomotor ataxia, 2<;7 
hysterical, 281 
spurious, 281 
Loring's experiments, 78 
Lyssaphobia, 361 

MALE hysteria, 378 
Mastodynia, 431 
Mdniere's disease, 124 
Meningeal hemorrhage, 219 
Meningitis, acute and chronic spinal, 204 
symptoms of, 204 
granular, 52 
cerebro-spinal, 343 
causes of, 344 
definition of, 343 
diagnosis of, 345 
morbid anatomy and pathology 

of, 345 
prognosis of, 346 
symptoms of, 343 
synonyms of, 343 
treatment of, 346 
chronic cerebral, 0o 
causes of, 68 
diagnosis of, 68 
morbid anatomy and pa- 
thology ol 
prognosis of, h8 
symptoms of, 85 
treatment of, I B 
connected with cardiac disease, 51 
of the aged. ~>2 
rheumatic, 50 
senile. 52 
tubercular (granular), 52 

basal. •>:; 

causes 
development of 

diagnosis of, 68 

morbid anatomy and pat 
of, 

prognosis of. 

sj mptoms of, 

treatment 

tubercular deposits in. 81 

vertioal, 

vital sicn> in. 



510 



INDEX, 



Meningo-cerebvitis, 149 

Mental changes in locomotor ataxia, 279 

Migraine, 421 

Miliary aneurisms, 98 

Mimetic chorea, 400 

Morbid impulses in listeria, 372 

Mortality in tubercular meningitis, 58 

Mottled skiu iu pseudo-hypertrophic 

paralysis, 273 
Multiple embolism, 139 
Myelitis, 236 

causes of, 230 

chronic, 230 

diagnosis of, 237 

morbid anatomy and pathology of, 
237 

symptoms of, 236 

treatment of, 238 

vesical troubles in, 235 

VTERVES, tumors of, 451 
1M Neuralgia, age and sex in causation 
of, 434 

association with epilepsy, 432 

bad teeth as a cause of, 434 

causes of, 432 

cervico-occipital, 426 

circulatory disturbances in, 420 

clavus, 423 

coarse and fine varieties of, 439 

connection with pulmonary disease, 
432 

crural, 4 

definition of, 419 

diagnosis of, 430 

electricity in treatment of, 442 

excision of supra-orbital in, 424 

facial, 421 

influence of temperature in, 435 

intercostal, 428 

inveterate case of, an, 437 

morbid anatomy of, 436 

nerve areas in, 441 

nerve section in. 432 

of testis, 424 

ovarian, 431 

pain of, 419 

prognosis of, 436 

renal, 431 
sciatic, 428 
syphilitic, 422 
treatment of, 438 
trigeminal, 42 1 
trophic disturbances in, 420 
urethral, -13 1 
risoeral, 480 
Neuritis, 444 

causes of, 446 

morbid anatomy and pathology of, 

446 
nerve leotlon in, 1 17 

1 1 1 etching in, l 17 
prognosis of, 4 17 
■j 1 1 1 j > i < > i ■ i -. of, 1 1 1 
n e itment of, 147 



Neuritis (continued). 

trophic changes in, 445 
Neuromata, sarcomatous, 452 

treatment of, 452 
Nystagmus, 189 

OCCLUSION of intracranial vessels, 129 
Occupation, and its relation to cere- 
bral hyperoemia, 73 
Ocular trouble with brain tumor, 187 
Ophthalmoscope, the, 28 
Opisthotonos, 290 

Organs of speech, affection of in chorea, 
394 

PACHYMENINGITIS as a result of in- 
jury, 35 
spinal, causes of, 207 

diagnosis of, 211 

morbid anatomy and pathology 
of, 208 

prognosis of, 210 

symptoms of, 206 

treatment of, 211 
Painters' colic, 470 
Palsy, Scrivener's, 486 
shaking, 406 
wasting, 255 
Paralysis, adult spinal, 247 
after dislocation, 461 
agitans, 406 

case of, 408 

causes of, 408 

diagnosis of, 410 

morbid anatomy and pathology 
of, 409 

prognosis of, 411 

symptoms of, 407 

synonyms of, 406 

treatment of, 41 1 
antero-spinal, of infancy, 239 
bulbar, 336 
cross, 89 

Cruveilhier's, 255 
diphtheritic, 460 

case of, 407 

causes of, 468 

diagnosis of, 469 

morbid anatomy and pathology 
of, 408 

prognosis of, 469 

symptoms of. 467 

treatment of, 469 
facial, 458 
from pressure of forceps, 462 

beat in the treatment of, 1 1 1 

hysterical, 375 

local, 458 

of cranial nerves, 277 

of sphincters, 23,") 

pseudo-hypertrophic, 269 

residual, 88 
temporary spinal, 251 
traumatio, 158 

Paralytic chorea, 896 



INDEX. 



511 



Paraplegia, 234 

hysterical, 375 
Parkinsou's disease, 406 
Partial cerebral anaemia, 113 
Passive cerebral hyperemia, 09 
Pathology of spasm, 483 
Perivascular spaces, the, 75 
Petrina on localization, 200 
Piesmeter, the, 26 
Pleurodynia, 428 
Pleurosthotonos, 296 
Poisoning, lead, 470 
Posterior spinal sclerosis, 276 

ascending and descending, 
277 

bladder complication in, 277 

causes of, 281 

diagnosis of, 286 

morbid anatomy and pa- 
thology of, 282 

neuralgia in, 276 

prognosis of, 287 

state of mind in, 277 

symptoms of, 276 

synonyms of, 276 

treatment of, 287 
Post-hemiplegic disordersof movement, 92 
Post-paralytic chorea, 92 
Primary and compensatory contractions 

in paralysis, 240 
Prodromata of infantile palsy, 239 
Professional cramp, 484 

muscular atrophy, 486 
Progressive muscular atrophy, 255 

causes of, 258 

definition of, 255 

diagnosis of, 363 

history of, 255 

morbid anatomy and pa- 
thology of, 259 

prognosis of, 2(55 

resembling lead palsy, 263 

symptoms of, 255 

synonyms of, 255 

treatment of, 255 
Pseudo-hypertrophic muscular paralysis, 
269 

cases of, 271 

causes of, 273 

diagnosis of, 275 

heredity in, 273 

lordosis in, 272 

pathology and morbid an- 
atomy of, 27 1 

prognosis of. 27"> 

symptoms of, 269 

synonyms of. 269 

treatment of, 275 
Puerperal embolism, 1 12 
hysteria, 379 

RABIES carina, 861 
Reflex BpMm, 481 
Retraction of head in oerebro-spinal 

meningitis, 1 I 



Rigor, 86 
Elisua sardonicus, 

Romberg on delayed transmission of 
ful impressions, 286 

[lubber muscle, tl. 

SCIATICA, 428 
Sclerosis, antero-lateral. 2 
cerebral, IT'.* 
cerebrospinal, 818 
causes of, 850 
diagnosis of, 351 
morbid anatomy and pathology 

of, 350 
prognosis of, 851 
resembling paralysis agitans, 351 
stages of, 846 
symptoms of, ; ; 16 
synonyms of, '■'• 16 
treatment of, 351 
lateral, 293 
posterior-spinal. 27 
Sclerose en plaqn< . 346 
Scrivener's palsy, 486 
Seat of cerebral hemorrhage, 
Senile meningitis. 52 
Seventh nerve, paralysis of, 457 
Shaking palsy, 400 
Sieveking's lesthesiometer, 22 
Simple apoplexy. 
Sleep not necessarily due to cerebral 

anaemia, 120 
Softening after vascular plugging, 134 
cerebral, 148 

not necessarily an inflammatory pro- 
cess, 148 
of posterior columns in tetanus, 303 
Spaces, the perivascular, 75 
Spasm, facial, without pain, 482 
from genital irritation. 4>1 
functional, 479 

with voluntary movement! 
pathology of, I s "> 
reflex. 181 
treatment of. 
Spinal ansemia, so-called. 227 

Gibnev on traumatic causation 

of, 226 
Griffin on. 227 
congestion, 223 

symptoms of, 228 
hemorrhage, 5 
oaoses of, 219 

diagnosis of, 221 

morbid anatom; 
of, 220 

pr< -21 

sympton 

treatment <>(, 
bypersemia, bu) 

dii. 



512 



INDEX. 



Spinal hyperemia, subacute {continued). 
prognosis of, 226 
symptoms of, 224 
treatment of, 226 
irritation, 227 

causes of, 229 

diagnosis of, 231 

morbid anatomy and pathology 

of, 230 
prognosis of, 231 
symptoms of, 227 
treatment of, 231 
meninges, diseases of, 204 
meningitis, acute and chronic, 204 
pachymeningitis, 206 
causes of, 207 
symptoms of, 206 
paralysis, temporary, 251 
tumor, 213 

causes of, 217 

diagnosis of, 218 

morbid auatomy and pathology 

of, 218 
prognosis of, 218 
symptoms of, 213 
treatment of, 218 
varieties of, 213 
Spurious locomotor ataxia, 281 
Staining solutions, 21 
Sthenic cerebral hyperemia, 60 
Stomachic vertigo, 123 
St. Vitus' dance, 393 
Syncope, 113 
Syphilis of the brain, 192 
Syphilitic epilepsy, 325 
pachymeningitis, 37 

TABES dorsalis, 276 
Tache carebrale, 56 
Tarantism, 393 

Temporary spinal paralysis, 251 
Tetanus, 303 

allied to strychnia poisoning, 303 

causes of, 298 

curare in, 807 

definition of, 295 

diagnosis of, 305 

endemic, 299 

morbid anatomy and pathology of, 
802 

naseentinm, 2H7 

pleurosthotonofl in, 296 

prognosis of, 805 

risua sardonious in, 296 

softening of posterior column in, 303 

statistios, 806 



Tetanus (continued). 
symptoms of, 295 
synonyms of, 295 
treatment of, 306 
urine in, 297 
Tetany, 480 
The epileptic zone, 322 
Theory of sleep, 120 
Thermometer, the, 22 
Thrombosis, 129 

of cerebral arteries, 129 
case of, 130 
causes of, 133 
diagnosis of, 135 
morbid anatomy and pa- 
thology of, 133 
treatment of, 135 
of sinuses and veins, 135 

after aural disease, 135 ' 
Tic douleureux, 420 

epileptiform, 425 
Torticollis, 483 
Traumatic paralysis, 463 
diagnosis of, 463 
prognosis of, 463 
treatment of, 464 
Treatment of bed-sores, 238 

of spasm, 483 
Tremor, 409 

functional, 410 
Trismus nascentium, 297 
Trophic changes in traumatic paralysis, 

460 
Tubercular deposit in motor centre, 61 
Tumors of brain, 185 
of nerves, 451 
spinal, 213 

UNILATERAL tremor as a result of 
localized meningitis, 46 
Unreliability of post-mortem appearances 

in hydrophobia, 367 
Urine in tetanus, 297 



VARIATIONS of temperature in cere- 
bral 



hemorrhage, 86 
Vertigo, 123 



WIRE hook in treatment of facial 
paralysis, 458 
Writers' cramp, 484 



Z ONK 



, the epileptic, 321 



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Following this is the "Review Department/' containing extended and impartial 
reviews ol important new works, together with numerous elaborate "Analytical and 
Bibliographical Notices" giving a complete survey of medical literature. 

This is followed by the "Quarterly Summary of Improvements and Discoveries 
IN the Medical Sciences," classified and arranged under different heads, presenting 
a very complete digest of medical progress abroad as well as at home. 

Thus, during the year 1877, the 'Journal" furnished to its subscribers 101 Original 
Communications, 135 Reviews and Bibliographical Notices, ami 227 articles in the 
Quarterly Summaries, making a total of Four Hundred and Sixty-three articles 
illustrated with (14 maps and wood engravings, emanating from the best professional 
minds in America and Europe. 

That the efforts thus made to maintain the high reputation of the "Journal" are 
successful, is shown by the position accorded to it in both America and Europe as a 
leading organ of medical progress: — 



This i* universally acknowledged as the leading 
American Journal, and lias been coudncted by Dr. 
Hhvs alone until l P69, when his sou was associated 



The Philadelphia Medical and Physical Journal 
issued its first cumber in 1820, and alter a brilliant 
career, was succeeded in 1827 by ihe American 



with hiin. We quite agree with the critic, that this Journal of the Medical Sciences, a peiiodical of 
journal i? stcoud to none in the language, aud cheer- I world-wide reputation; the ablest and one of f 



fully accord to it the first place, for nowhere shall 
we find more able and more impartial criticism, aud. 
nowhere such a repertory of able original articles 
Indeed, now that the "Brilish and Fore gn Medicn- 
Chirurgical Review" has terminated its career, the 
iu Journal stands without a ri val.— London 
Med. Times and Gazette, Nov. 2i, 1877. 

The present number of the American Journal is an 
exceedingly good one, and gives eveiy promise of 
maintaining the well-earned reputation of the review 
Our venerable contemporary has our best wishes 
and we cau only express the hope that it may con 



oldest periodicals iu the world— a journal which has 
an unsullied record. — Gross's History a/ An 
Med. Literature, lSTti. 

It is universally acknowledged to be the leading 
American medical journal, aud, in our opinion, is 
second to none in tiie language — Boston Med. and 
tiary. Journal, Oct. Is77. 

This is the medical journal of onr country to which 
the American physician abroad will point with the 
greatest saii faction, as reflecting the state of medical 
culture iu bin country. For a great many years it 
ha-; been the medium through which our ablest writ- 
tinue its work with as much vigor and excellence for era have made known their discovering and obsei va- 
the next flf y years as it has exhibited in the past, tions —Address of L. P. Yandelt, Ml)., be/ort 

n Lancet, Nov. U, \"~~- ! national Med. Congress, Kept, istu 

And that it was specifically included in the award of a medal of merit to the Publisher 
in the Vienna Exhibition in L873. 

The subscription price of tin- 'American Journal of the Medical Sciences" has 
never! ed during its long oareer. It is still Five Dollars per annum; ami 

when paid for in advance, the subscriber receives in addition the " Medical N ews and 
LIBRARY," making in all about 1500 large octavo pages per annum, free of postage. 

II. 
THE MEDICAL HKWS AND LIBRARY 

is a monthly periodical of Thirty-two large octavo pages, making 384 pages per 

annum. Its "Librae* Department" is devoted to publishing standard works on the 

i6 branches <>i medical Bcience, paged separately, so thai they can lie detached 

for binding, when complete. In this manner subscribers have received, without e.\- 

ii. h works as "Watson's Practice," •' West om Children," "Malgaione'h 

ok Fever," and many other volumes of the highest reputation 

and o efuloess. With .July, L87o; was commenced the publication of Gosseltn's 

translated from the French by Lewis a.-Stim- 

eon to lie Presbyterian Hospital. New tfork (see p. 28), which will 

impleted during the year 1878, and will be followed by another volume of equal 



alerted 
ure paid for b; 



Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 



practical value. New subscribers, commencing with dan. L878, can procure the pre- 
vious portions of "Gosselin" by a remittance of $1.50, if promptly made. 

The "News Department" of the "Medical News and Library' 1 pre 
current information of the month, with Clinical Lectures and Hospital Gleanings. 
A new and attractive feature of this will be found in an elaborate series of Original 
American Oltnical Lectures, specially contributed to the News by gentlemen of 
the highest reputation in the profession throughout the United States. The arrange- 
ments for this are not as yet completed, but already the co-operation hae 
secured of the following: — 

8. I). Gross, M.D., Prof, of Surgery, Jefferson Med Coll , Philada. 

Austin Flint, M.D., Prof. Prin. and Prac, of Med., Bellevue Hosp Wed. Col] . N . y 

S. Weir Mitchell, Ml)., Phys. to the Infirmary for Nervous Diseases, Philada. 

T. (jatllard Thomas, ML)., Prof. Obstetrics. &c, Coll. Phys. and Burg, N Y 

J. M. DaOosta, M.D., Prof. Prin. and Prac. of Med . Jeff. Med. Coll., Philada. 

.Roberts Bartholow, M.D., Prof. Theory and Practice of Med., M jd. Coll. of Ohio. 

T. G. Richardson, M IX, Prof. Genl. and Clin. .Sunj., Univ. of La., New Or! 

William Goodell. M.D.. Prof. Clin. Gynaecology, Univ. of Penna. 

Fordyoe Barker, M.D., Prof. Clin. Midwifery, &c, Bellevue Hosp. Med. Coll N Y 

N. S. Davis, M.D., Prof. Prin and Prac. of Med., Chicago Med. Cull. 

L. A. Duhring, M.D.. Clin. Prof, of Diseases of the Skin, Univ. of Penna. 

Theophilos Parvin.M.D., Prof. Obstetrics, &c. Coll. Phys. and Surg., I ndianapolis. 

Lewts A.Sayre, M.D., Prof. Orthopaedic Surg., &c. Bellevue Hosp. Med Coll., X Y 

AY. II. Van Buren, M.D., Prof. Surgery, Bellevue Hosp. Med. Coll., X. Y. 

J. P. White, M D„ Prof, of Obstetrics, &c, Univ. of Buffalo. 

John Asiiiiurst, Jr., M D , Prof, of Clin. Surg., Univ. of Penna. 

D. Warren Brickell, M.D., Prof. Obstetrics, &c, Chanty Hosp. Med Coll., X". 0. 

William Pepper, M.D., Prof. Clin. Medicine, Univ. of Penna. 

J. Lewis Smith, M.I.)., Clin. Lee. on Dis. of Chil., Bellevue Hosp Med. Coll.. X". Y. 

William F. Xorris, M.D., Cliu. Prof, of Diseases of the Bye. Univ. of Penna. 

P. S. Conner, M.D., Prof, of Anat. and Clin. Surgery, Med. Coll. of Ohio, (Jin. 

Thomas Gt. Morton, MD, Surgeon to Penna. Hospital, Philada. 

F. J. Bumstead, M.D., late Prof, of Venereal Dis., Coll. Phys. and Surg., X. Y. 

J. II. Hutchinson, MI)., Physician to Penna. Hospital. 

F. Peyre Porcher, M.D . Prof, of Mat. Med. and Clin. Medicine. Med. Coll. of S.C 

Christopher Johnson, M.D., Prof, of Surgery, Univ. of Md., Baltimore. 

S. W. Gross, M.D., Snrg. to Philada. Hospital. 

William Thomson, M D., Lecturer on Ophthalmology, Jeff. Med. Coll., Philada. 

With contributors such as these, representing every portion of the United S; 
the publisher feels safe in promising to the subscriber a series of practical lectures 
unsurpassed in variety, interest, and value. 

As stated above, the subscription price of the " Medical X t e\vs and Ltbrai:\ 
One Dollar per annum in advance; and it is furnished without charge to all advance 
paying subscribers to the "American Journal of the Medical Sciences." 

III. 

THE MOKTHLY ABSTRACT OF MEDICAL SCIENCE 

is issued on the first of every mouth, each number containing forty-eight large o< 
pages, thus furnishing in the course of the year about six hundred pages. The aim 
of the Abstract is to present— without duplicating the matter in the u Journal" 
and ''News" — a careful condensation of all that is new and important in the medical 
journalism of the world, and all the prominent professional periodicals of both hemi 
spheres are at the disposal of the Editors. To show the manner in which this plan 
has been carried out it is sufficient to slate that during the year 1877 it contained 

.'i'i Articles on Anatomy and Phy*iolopy. 

S2 " '• Miii '■>• in Medica and Therapeutics, 

J'. Hi " " Mrdirine. 

140 " «• fiurg*n/. 

,S9 '■ " Midwifery and Gynaecology, 

9 " " Mad-teal Jurtsprudcnc <""' / uicotor/y— 

making in all :V_!7 articles in a single year. 

The subscription to the " Monthly ABSTRACT," fret 1 of postage, is Two 

and \ II ale a year, in advance. 

As stated above, however, it will be supplied in conjunction with the "American 
Journal of the M bdioal Sciences" and the "Medical News ind Library," ma 
in all about Twenty-one lli ndred pages per annum, tin* whole. 

Sin DOLLARS a year, in advance. 

In this effort to bring so large an amount of practical information within the !• 
of every member ofthe profession, the publisher eonii leotlv anticipates the Ire ; 



Henry C. Lea's Publications — (Dictionaries). 



aid off all who are interested in the dissemination of sound medical literature. He 
trusts, especially, that the subscribers to the "American Medical Journal" will call 
the attention off their acquaintances to the advantages thus offered, and that he will 
be sustained in the endeavor to permanently establish medical periodical literature 
on a looting of cheapness never heretofore attempted. 

PREMIUM TOR OBTAINING NEW SUBSCRIBERS TO THE "JOURNAL." 

Any gentleman who will remit the amount for two subscriptions for 1878, one of 
which must be for a new salsa/her, will receive as a premium, tree by mail, a copy of 
■ Browne on the Usr of the Ophthalmoscope" (for advertisement of which see p. 
2i>), or of "Fox on Skin Diseases" (see p. 20), or of "Flint's Essays on Conserva- 
tive Medicine" (see p. 15), or of ".Sturgks's Clinical Medicine" (see p. 14), or of 
the new edition of "Swayne's Obstrtkio Aphorisms" (see p. 25), or of "Tanner'* 
Clinical Manual" (see p. 5), or of "Chambers's Restorative Medicine" (see p. 
L8), or of " West on Nervous Disorders of Children ' (see p. 21). 

*^* Gentlemen desiring to avail themselves of the advantages thus offered will do 
well to forward their subscriptions at an early day, in order to insure the receipt of 
complete sets for the year lb78. 

^° The safest mode of remittance is by bank check or postal money order, drawn 
to the order of the undersigned. Where these are not accessible, remittances for the 
'•Journal" may be made at the risk of the publisher, by forwarding in registkred 
letters. Address. 

HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadei phia, Pa. 



T)UNGLISON {ROBLEY), M.D., 

"^ Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

MEPICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subject? and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medic 1 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulas fo? 
Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology cf 
the Terms, and the French and other Synonymes; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Bichard J. Dunglison, M.D. In one very large and hand- 
some royal octavo volume ol over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. 
( Just Issued.) 
The object of the author from the outset has not been to make the work a mere lexicon < r 
dictionary of terms, but to afford, under each, a condensed view of its various medical relatior s, 
aud thus to render the work an epitome of the existing condition of medical science. Starting 
with thia view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the positic n 
of a recognized and standard authority wherever frhe language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en 
viable reputation. During the t< n years which have elapsed since the last revision, the additioi s 
to the nomenclature of the medical sciences have been greater than perhaps in any similar period 
of the past, and np to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practi ioner Since then, the editor has been 
equally industl ions, so that t be additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typ graphical arrangement has been much improved, rendering 
reference much more easy, and ev?ry care has been taken with the mechanical execution. The 
vork bat been printed on new type, small but exceedingly clear, with an enlarged page, so that 
i e addition! bate been inoorpoi ited with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 
a book well known to our read urn, mid of wind. 



■ D erlcan on i'i to be proud. V7hi o the learned 
author of tin- work passed away, probably nil of us 
riu old di t maintain it* y\m-v 
ii, the advanc bc«e terms it defines, (for 

Richard ■' Dunglta d, having assisted bi* 
fathei I ■ "i everal edition! ol the woi k, 

and bavins been, then fore, trained in the methods and 
Imbued witi' the s|>irii ol the book, bai been able t<> 



lory of technical terms is simply a tine ijun non. In a 
iclenre bo ex ten Ivi . and with such collaterals ax medi- 
tine, it is ax much a necessity also to the practising 
ihysician. To ai •■•( the wants of students and most 
physicians, the dictionary most be condensed while 
tomprebensive, and practioal while perspicacious, It 
mi- because DungUs* u - met these Indications that it 
became at our.' the dictionary of general use wherever 
dti Ine wee studied In the Rnsllsb language. In no 



the patchwork manner so dear to the former revision have the alterations and additions been 
epul Ive to the taste ofTntel logrnat. M-jruthan hIx tliousaud new subjects and term 
It gen I i oos I- adi r . bul toe( Itil ai -^ s orfc 'jH 



kind 
ihould i • err) it on steadily, without Jar 

■ hi in, ii. ni< i of tl ought it ha* 

: . ,,,,. TO -!'"« the li.;i: iiiliul. 

i i.h Dr Dungll i d ha ■ isomnd nod par 

to t.ii.- thi i more 
ivab en addi d Id the 

il . mil ,, PhQa Ued. />»,,.. Inn ::, is? j 

Mi. ,ui ii ■■ i.r i i k pon ha ed by the i 

I,.- m. .in Hi i>i ii"iuir>. 1 plana 



lave been added. The chief terms bavel nsel In Muck 

••tier, while ilie derivatives follow in small raps; an 
ii Km emenl whlcb greatlj facilitates reference. °Fe 
may safely confirm the hope ventured bj the editor 
• thai the work . a hich possesses for bin) a (Wales well 
i- an Individual interest, will i>e found worth) ■ son* 
Clnuance ol ' , ''' p i Itli n '" lonst accorded to it as a 
itnndard authority ." Cincinnati Clinic, Jan. 10, 1S74. 
it baa the fare merit t bat it oertalnly has noriv i 
in i he Bogllab lengnagi for aooaraoy audexten? id 
■ es. — London Medical dinette. 



TIenry C. Lea's Publications — (Manuals). 



A CENTURY OF AMERICAN MEDICINE. L776-1876. Bj Dodo,- K. H. 

-* 1 - Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In on 
some 12ino. volume of about 350 pages : cloth, $2 25. {Just Ready.) 
This work has appeared in the pages of the American Journal of Medical Sciences luring the 
year 1876. As a detailed account of the development of medical science in America, by 
men of the highest authority in their respective departments, the profession will no doubt wel- 
come it in a form adapted for preservation and reference. 



n 



OBLYN {RICHARD D.), M.D. 



R 



A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hats, 
M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 
12mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leather, $2 00. 

Tt Is the best book of definitions we have, and ought always to be upon the student'* table. — flouf/v, n 
M-d. and Surg. Journal. 

OD WELL (G. F), F.R.A.S.. &c 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light. Magnetism, 

Mechanics, Meteorology, Pneumatics, Sound, nnd Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of d'J-i pages, and 
many illustrations: cloth, $5. 

WEILL {JOHN), M.D., and UMITH {FRANCIS G.), M.D., 

** * Prof, of the Institutesof Medicine in the Univ. of Penna 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 1 2mo . 
volume, of about one thousand pages, with 374 wood cuts, cloth, $4 ; strongly bounc in 
leather, with raised bands, $4 75. 



H 



ARTSHORNE {HENRY), M.D. , 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. C.oth, $4 25 ; leather, $5 00. (Lately Issued.) 
We can say with the strictest truth that it is the I dents, but to many others who may desire to refre-h 
best work of the kind with which we areacqnaiuted I their memories with the smallest possible expendt- 
It embodies iu a condensed form all recent coutribu- I ture of time. — N. Y. Med. Journal, Sept. 1S74. 
tionsto practical medicine, and is therefore useful f The studeat will find this the most convenient an d 
toevery busy practitioner throughout our country, useful book of the kiud 0Q which he caQ |ay , us 
besides being admirably adapted to the use of stu- naad ._p ttC ^ c Med and Surg j ourn A „- lS74 



dents of medicine. The book is faithfully and ably 
executed.— Charleston Med. Journ., April, 1S75. 

The work is intended as an aid to the medical stu- 
dent, aud as such appears to admirably fulfil its ob- 
ject by its excellent arrangement, the full compilation 
of facts, the perspicuity ac.d terseness of lauguage, 
and the clear and instructive illustrations iu some 
parts of the work —American Journ. of Pharmacy, 
Philadelphia, July, 1874. 

The volume will be found useful, not only to stu- 



This is the best book of its kind that we h.«. ■. 
examined. It is an honest, accurate, and i 
compend of medical sciences, as fairly as ; 
representing their present condition. The chant.* - 
and the additions have been so judicious and thorough 
as to render it, so far as it goes, entirely trustworthy. 
If students must have a conspec a - 
to procure that of Dr Hartshorue. — Ihtroil 
Med and Pkarm., Aug 1S74. 



L 



UDLOW {J.L.), M.D. 

A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica. Chemistry, Pharmacy. %i d 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly re 
and greatly extended and enlarged. With 870 illustrations. In one handsome royal 
12mo. volume of 816 large pages, cloth, $H 25 ; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit 
a >le for the office examination of students, and for those preparing for graduation 



/TANNER {THOMAS HA WKB8), M. />.. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAO- 

NOSIS. Third American from the Second London Edition. 

TiLBliRY Fox, M. D., Physician to the Skin Department in Tnivet- 11 rpttal, 

Ac. In one neat volume small ISmo., ofabontSTfi fch, $160. 

*#* On page 4, it will be seen that this work i? offered M I preniitun for procuring new 
subscribers to the " American Jot una L OF ruK M IDIC i l mikncks." 



Henry C. Lea's Publications — (Anatomy). 



ffRAT (HENRY), F.R.S., 

L-rturer on Anatomy at St. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- 
tions jointly by the Author and Dr. Cartjbr. A new American, from the fifth enlarged 
and improved London edition. In one magnificent imperial octavo volume, of nearly 900 
pages, with 465 large and elaborate engravings on wood. Price in cloth, $6 00 ; lea- 
ther, raised bands, $7 00 {Latch/ Published.) 
The author ha* endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the leirner, and an admirable work of reference for the active practitioner, 
graving* 



The en- 
gs form a special feature in the work, many of them being the size of nature, nearly nil 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the student in obtaining a elear idea of Anatomy, and will also serve tc 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Notwithstanding the enlargement of this edition, it has been kept at its former very moderate 
price, rendering it one of the cheapest works now before the profession. 

The illustrations are beautifully executed, and ren- From time to time, as successive editions have a p- 
der this work an indispensable adjuuct to the library peared, we have had much pleasure in expressing 
ot r the Burgeon. This remark applies with great force the general judgment of the wonderful excellence of 
to those surgeons practising at a distance from our Gray's Anatomy. — Cincinnati Lancet, July, 1870. 
Large cities, as the opportunity of refreshing their Altogether, it is unquestionably the most complete 
memory by actual dissection Is not always attain-! aD( j serviceable text-book in anatomy that has ever 



able.— Canada Jfed Journal, Aug. 1S70. 

The work is too well known and appreciated by the 

need any comment. No medical man 

can afford to be without it, if its only merit were to 

serve as a reminder of that which so soon becomes 

forgotten, when not called into frequent use, viz., the 



been presented to the student, and forms a striking 
contrast to the dry and perplexing volumes on the 
same subject through which their predecessors strug- 
gled in days gone by — JV. r. Med. Record, June 15, 
1870. 
To commend Gray's Anatomy to the medical pro- 



relations and names of the complex organism of the f e . ssion is a ] most a8 " much a work of supererogation 
human body. The present edition is much improved. | ag it would be to give a favorable notice of the Bible 
-.California Med Gazette, July, 1870. N n tne religious press. To say that it is the most 

Gray's Anatomy has been so long the standard of j complete and conveniently arranged text-book of it* 
perfection with every student of anatomy, that we kind, is to repeat what each generation of students 
need do no more than call attention to the improve- j has learned as a tradition of the elders, and verified 
ment in the present edition.— Detroit Review of Med-, by personal experience. — N Y. Med. Oatette, Dec. 
and Pharm., Aug. 1870. I 17, 1870. 



UMITH {HENRTH.), M.D., and JJORNER ( WILLIAM E.),M.D., 

Prof, of Surgery in the Univ. of Penna., Ac. *Late Prof, of Anatomy in the Univ. ofPenna., <*«■ . 

AN ANATOMICAL ATLAS, illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiful figures. $4 50. 
The plan of this Atlas, which renders it so pecu- I the kind that has yet appeared ; and we must add, 
llarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up," 
cecatlou, have been already pointed out. We j is so creditable to the country as to be flattering tc 
congratulate the student upon the completion our national pride.— American Medical Journal. 
o<" this Atlas, as it is the most convenient work of I 



&CHAFER (EDWARD ALBERT), M.D., 

A j i.'unt Professor of Physiology in University College, Jjondon. 

A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 

the Use of the Microaoope. In one handsome royal 12mo. volume of 304 pages, with 
numerous illustrations: cloth, $2 00. {Just Issued,! 

W<- are ■•'■rv Ch pleased With the book. Which he has Bald his say. The book ha* also th(> still 

tudent limply how to use his instruments more nncommou merll of bearing iverywbere the 
nii.i conduct bis studies without going further Into the Impress of the anthor's own thought. There Is do 



plcanatomj of the tissues and organ* than la 

\\ hut we particularly i 

In which H take* tbestudenl bj the hand, 

iwlng him wbal t" do, and explaining 

pimply, bti I thoroughly, how to d Med.dnd 

As a whole, the i">"k Is an admirable one. The 
ef, tn» Hi' y ar< cleai i nd de All 
: • .i the art ol ■ topple 



encb thing In the book as a condensation of a chap 
t'T, or a< ctlon or pa i sgra ph from ■ ny «'u e else. Bi en 
when deacrl dngsome of I be commonest proci 
shows such a practical familiarity wtfh lbs dstBlla 
bs to give his description the flavor of originality, Id 
conclusion, we can confidently recommend ih<' work 
ag the mosl useful manual for the practical nl*'o)o< 
gist w ih which we are acquainted —Chicago Mtd 
journ. "mi Exam , Bepi 1877. 



181'EOIAL ANATOMY AND HIBTOLOO* 8HARPSY AND QUAIN'S HUMAN ANATOMY. I,v 

rlsed,with Notes and Additions, by Joseph Liidt, 
ai i>., Professor of Anatomy In the Uulvtrslty of 
Pennsylvania Complete In i«-., large octavo voi- 
amss ni hi i 1300 pages, with 011 lllastra 



Kmhih ed r< rised and modified 

in.: if OTer 1009 pngee, with more thai 

,.,, * i [otb. Ifl IW 

■ i. DTMBCTIONl Beoond 
thot i i n one neal i 

i :ni" i olame, I 



Henry C. Lea's Publications— (Anatomy). 



A LLEN {HARBISON, M.D.), 

-^*- ProfiSSOr of Comparative Anatomy in the Univ. of Pa. 

A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 

and Surgical Relations. For the Use of Practitioners and Students of Medicine. With .in 
Introductory Chapter on Histology. By E. 0. Siiakksi-kauk, M L> , Ophthalmologist to the 
Phila. Ilosp. In one large and handsome quarto volume, with several hundred original 
illustration* on lithographic plates, and numerous wood-cut- in the teit. [Prepan 
In this elaborate work, which has been in active preparation for several years, the author has 
sought to give, not only the details of descriptive anatomy in a clear and condensed form, I i 
the practical applications of the science to medicine and surgery. The work thus has claim! 
the attention of the general practitioner, as well as of the student, enabling him not only to re- 
fresh his recollections of the dissecting room, but also to recognize the Bignific 1 varia- 
tions from normal conditions. The marked utility of the object thus sought by the author is 
self-evident, and his long experience and assiduous devotion to its thorough develop. merit are a 
sufficient guarantee of the manner in which his aims have been carried out. No pains have been 
spared with the illustrations. Those of normal anatomy are from original rjissecti us. drawn on 
stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, 
after the manner of "Holden" and "Gray" and in every typographical detail it will b e the 
effort of the publisher to render the volume worthy of the very distinguished position which id 
anticipated for it. 



w 



ILSON {ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

by W.H. Gobrecht, M.D., Professor of General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather $5. 

ZJEATH {CHRISTOPHER), F. R. C. S., 

*>-*■ Teacher of Operative. Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From tie 

Second revised and improved London edition. Edited, with additions, by W. W. Keen 

M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphi; ! 

In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Clot h $3 50 - 

leather, $4 00. 
"In presenting this American edition >f ' Heath's 'ndeed, we do not hesitate to say, the best of its class 
Practical Anatomy,' I feel that I have ieen lu- vith which we are acquainted ; resembling Wil*. n 
stramenta) in supplying a want long felt for a in terse and clear description, excelling most of tie 
i real dissector's manual,*' and this assertion of its » >-called practical anatomical dieeectoie in the scope 
sditor we deem is fully justified, after an examina- of the subject and practical selected matter 
tion of its contents, for it is really an excellent work. - St. Louis Med. and Surg. Journal, Mar. 10, 187 

T>ELLAMY{E.),F.R.C.S. 

THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- 

Book for Students preparing for their Pass Examination. With engravings on wood. Ic 
one handsome royal 12mo. volume. Cloth. $2 25. (Lately Published.) 
We welcome Mr. Bellamys work, as a contri)iu- I clear and concise style, and its practical - 
tion to the study of regional anatomy, of equal value idd largely to the interest attaching to lln 
to the student and the surgeon. It is written ;n a | let ails — Chicago Mtd. Examiner, March i 

JJOLDEN [LUTHER], F.R.C.S, 

•II Surgemi to St. B irtholomew 8 and the Foundling Hospitals. 

LANDMARKS, MEDICAL AND SURGICAL. From the 2d London 

Ed. In one handsome volume, royal l2mo., of 128 pages : cloth, 88 cents. (/ j 

" My object has been to collect into a compact form the leading landmarks which help Bars 
in their daily work. Those relating to the chest and abdomen have been ascertained, «i 
much precision as natural variations permit, by needles introduced in vurious directions 
Prom the Author's Preface. 

There are few practitioners, whose knowledge is not refreshed by constant attendance in the 
dissecting room, who do not at times feel the need of such an assistant as this little work to 
enable them to determine on the instant from external observation of the position of internnl 
Structures. The student also will find it a convenient guide and assistant in oonjunotion with 
his anatomical text-books. Mr. Holden's distinguished reputation . rate .ui.it 

gives assurance that the volume contains all the suggestions o{ this nature that are readily 
available, set forth in a form to command public confidence. 

it is easy reading, because the writing of it has beeu bard, it is at once accurate, sonoiae, aud practical. 
— V.diu'nu'-'jit Med* cat Journal. 

S1LELAND (JOHN), Ml)., 

\J Professor of -< natomy and Physiology in Queen's Colleg- . 

A DIRECTOR! FOR THE DISSECTION OF THE HUMAN 

In one small volume, royal L2mo. of 182 pages; oil 1 b 



Tin* is a plain, convenient, dissecting guide, to be 

used over i * » « * Bubjeot. As such, it will com nd it 

selfto tbectudeui by the lucid composition and dis- 
tinct dlreotlonc of the author.— Med. an 
Reporter, feh. 1877. 
This volume does uot interfere with the t.\ 



in oomm n esc, bol m< relj in] . m, » n .i 

ipl to perp i 

. mi the pocka 

_ 
v f. Mtd. Jot . y 






8 Henry C. Lea's Publications — (Physiology). 

/CARPENTER [WILLIAM B.), M.D., F. R. S.„ F.G.S., F.L.S., 

^ Registrar to University of London, etc. 

PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by Henry Power, 

MB. Lond., F R.C.S., Examiner in Natural Sciences, University of Oxford. Anew 
American from the Eighth Revised and Enlarged English Edition, -with Notes and Addi- 
tions, by Francis G. Smith, M. D., Professor of the Institutes cf Medicine in the Univer- 
sity of Pennsylvania, etc. In one very large and handsome octaA o volume, of 1 083 pages, 
with tv opiates and 373 engravings on wood; cloth, $5 50 ; leather, $6 50. [Jiist Issued.) 
The great work, the crowning labor of the distinguished author, and through which so many 
generations of students have acquired their knowledge of Physiology, has been almost metamor- 
phosed in the effort to a< apt it thoroughly to the requirements of modern science. Since the 
n ppearanee of the last American edition, it has had several revisions at the experienced hand of 
Mr. Power, who has modified and enlarged it so as to introduce all that is important in the 
investigation - and discoveries of England, France, and Germany, resulting in an enlargement of 
about one-fourth in the text. The series of illustrations has undergone a like revision, a large 
proportion of the former ones having been rejected, and the total number increased to nearly 
tour hundred The thorough revi*ion which the work has so recently received in England, has 
rendered unnecessary any elaborate additions in this country but the American Editor, Pro- 
fessor Smith, has introduced such matters as his long experience has shown him to be requisite 
for the student. Every care has been taken with the typographical execution, and the work is 
presented, with its thousand closely, but clearly printed pages, as emphatically the text-book for 
the student and practitioner of medicine — the one in which, as heretofore, especial care is directed 
to show the applications of phy.iology in the various practical branches of medical science. 
Notwithstanding its very great enlargement, the price has not been increased, rendering this 
one of the cheapest works now before the profession. 

We have been agreeably surprised to find the vol- 
ume so complete in regard to the structure and func- 
tbe nervous system in all its relations, a 



bubject that, in ma oy respects, is oue of the most diffi- 
cult of all, in the whole range of physiology, upon 
winch to produce a full and satisfactory treatise of 
the class to which the oue before us belongs. The 
additions by the American editor give to the work as 
El i% a considerable value beyond that of tha last 
English ediiion. In conclusion, we can give our cor- 
dial recommendation to the work as it now appears. 
The editors have, with their additions to the only 
work on physiology in our language that, in the full- 
esf sen e Ol the word, is the production of a philoso- 
pher as well as a physiologist, brought it up as fully 
! be expected, if not desired, to the standard 
of our knowledge of its subject at the prefent day. 
If will deservedly maintaiu the place it has always 
had in the favor of the medical profession. — Journ. 
■ "s mid Mental DU-ease, April, 1877. 
"Good wine needs no bush" says the proverb, and 
an old and faithful servant like the •' big" Carpenter, as 
carefully broughl down as this edition has been by Mr. 
Henry Power, needs liitle or no commendation by us. 
Buch enormous advances have recent y been made in our 
physiological knowledge, that what was perfectly new a 
year or two ago looks now as if it had been a received 
and established fart tor years. In this encyclopaedic 
w iv it in unrivalled. Here, ■<■ it seems to us, is the 
i) • of the book; one i> aafe in aending a student 
t'. it lot Information on almost any given subjeat, per- 



fectly certain of the fulness of information it will con- 
vey, and well satisfied of the accuracy with which it wil 
there be found stated. — London Mrd. Times and Gazette, 
Feb. 17, 1876. 

Thus fully are treated the structure and functions of all 
the important organs of the body, while there are chap- 
ters ousleep and somnambulism; chapters on ethnology , 
a full section on generation, and abundant references to 
the curiosities of physiology, as the evolution of light, 
heat, electricity, etc. In short, this new edition of Car- 
penter is, as we have said at the start, a very encyclo- 
pedia of modern physiology.— The Clinic. Feb. 84, 1S77. 

The merits of "Carpenter's Physiology are so widely 
known and appreciated that we need only allude briefly 
to the fact that in the latest edi ion will be found a com- 
prehensive embodiment of the results of recent physio 
logical investigation. Care has been taken to preserve 
the practical character of the original work. In fact 
the entire work has been brought up to date, and bears 
evidence of the amount of labor that has been bestowed 
upon it by its distinguished editor. Mr Henry Tower. 
The American editor lias made the latest additions, in 
order full v to cover the time that has elapse I since the 
last. English edition — X. V Med Journal, Jan. 1877. 

A more thorough work on physiology could not be 
found. In this all the facts discovered by the late re- 
searches are noticed, and neither student nor practi- 
tioner should be without this exhaustive treatise oti an 
important elementary branch of medicine. — Atlanta 
Med. and Surg, Journal, Dec. L876. 



ITIRKB& ( WILLIAM SENHOUSE), M.I). 

A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, 

M.D., F.R.C.S. A new American from the eighth and improved London edition. With 
about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
ume. Cloth, $:i 25; leather, $3 75. (Lately Issued.) 
Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, 
og within ;i narrow compass all that is important for the student. The rapidity with 

UOOegaive editions have followed each other in England has enabled the editor to keep it 

- ' > 1 ;■ On a le?el With Hie changes and new discoveries made in the science, and the eighth 

edition, Ol winch the present Ifl B reprint, has appeared BO recently that it may be regarded at 

i be latest aooesslble exposition of the subject. 



on lb- whole, there La rery little In the book 

. leal oi pi aetltlonei wil i n<>t nj»d 

.i in- a mi soaeisteal with our present 

■ in- rapldlj ohanging solenoe ; jfQd we 

tatioa in exprei sing on r opinion thai 

ol the beal handl ks on 

i : n oar langnage.— iV. F. 
■ April I.. : 
DOOfe ll admirably adapted to be placed In 



the bands of students, — Boston Med, <m<t Surg 
Journ., April lo 1873. 

In its enlarged form it is, In our opinion, still the 
besl book on physiology, most useful to the student. 
— I'hiia. Med. Time*, Lag. 30, 1878, 

'Iiiis is undoubtedly lli- best work for students of 
physiology extant. — Cincinnati Med. A'» mja, Sept. '7:<. 



II 



\RTSHORNE {HENRY) , .!/./>.. 

Profutor of UygUnt,tto ,int/i> UnUt o/F*nna, 

HANDBOOK OP ANATOMY AND PHYSIOLOGY. 



Second Edi- 



tion, rarisad. 1 n one roynl llinxj volume, with 220 wood cute : oloth, $1 76. (Just Isvtd.) 



Henry C. Lea's Publications — (Physiology). 



fkALTON {J. C), M.D., 

■IS Professor of Physiology in the College of Physicians and Surgeons, N«.w York, Sec. 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the Die 

of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
ume, of over 800 pages. Cloth, $5 50; leather, $6 50. {Just Issued.) 

From the Preface to the Sixth Edition. 

In the present edition of this book, while every part has received a careful revision, the ori- 
ginal plan of arrangement has been changed only so far as was necessary for the introduction of 
new material. 

The additions and alterations in the text, requisite to present concisely the growth of | 
physiological knowledge, h;ive resulted in spite of the author's earnest efforts at condensation, 
in an increase of fully fifty per cent, in the nutter of the work. A change, however, in the ty- 
pographical arrangement has accommodated these additions without undue enlargement in the 
bulk of the volume. 

The new chemical notation and nomenclature are introduced into the present edition, as hav- 
ing now so generally taken the place of the old, that no confusion need result from the change. 
The centigrade system of measurements for length, volume, and weight, i- also adopted, these 
measurements being at present almost universally employed in original physiological investiga- 
tions and their published accounts. Temperatures are given in degrees of the centigrade 
usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. 
New York, September, 1S75. 

Durinj: the past few years several new works on phy-i This popular text-book on physiology comes to us in 
Biology, and new editions of old works, have appeared, its Bixtb edition with the addition of about fifty percent. 
competing for the favor of the medical student, but none of new matter, chiefly in the departments of pa t bo- 
will rival this new edition of Dalton. As now enlarged, logical chemistry and the nervous system, where the 
i t will fce found also to be. in general, a satisfactory work principal advances have been realized. With so tho- 
of reference for the practitioner.— Chicago Med. Journ. rouirh revision and additions, that keep the work well 
and Examiner, Jan. 187.',. I up to the times, its continued popularity may be 

r» c tl i- i_ * a - .• iL j dently predicted, notwithstanding the competition it 

Prof. Dalton has discussed conflicting theories and encounter. The publisher's work is admirably 

conclusions regarding physiological questions with a , done ._ s ,. L , :in ;, M ed. and Surg. Journ , Dec. 1875 ' 
rairness, a fulness, and a conciseness which lend tresb- ■ 

ness and vigor to the entire book. But his discussions - We heartily welcome this, the sixth edition of this 
have been sn guarded by a refusal of admission to those admirable text book, than which there are none of equal 
speculative and theoretical explanations, which at best brevity more valuable. ^ It is cordially recommended by 
exist in the minds of observer* themselves as only pro- 
babilities, that none of his readers need be led into 
crave errors while making them a studv. — The Medical 
Record, Feb. 19, 1376. 



the Professor of Physiology in the University of Louisi- 
ana, a- by all competent teachers in the United States 
and wherever the English language is read, tl 
has been appreciated. The present edition, with it> • >!»'< 
. admirably executed illustrations, has been carefully 
.The revision of this great work has brought it forward revise(l and mucn enlarged, although its bulk does 

with thephysiological advances of the day. and renders not seem perceptiblv increased.— New Orleans I 



it, as it has ever heen, the finest work for studenis ex 
tant. — Nashville Journ. of Med. and Surg., Jan. IS 



and Surgical Journal, March, 1S76. 



The present edition is very much superior to every 
For clearness and perspicuity. Dalton s Physiology other £ ot only in that u brin?s the suhject to t)ie 
wmmended itself to the student years ago. and was a times but th . lt it d 9 . s0 m nre fully and satiemrtorttv 
pleasant relief trom the verbose productions which it thHnanypreviouseditmn.Takeitaltogether.it remains 
supplanted. Physiology has however made many ad- ln ourhumble opinion, the best text bookonpl 
vances Mnce then -and while the style has been pre- ia any land or linage.— The Clinic, N 
served intact, the work in the present edition nasi * 

broutrhtupfullvahreHstofthetitr.es. The new chemical As a whole, we cordially recommend the work 88 a 
notation and nomenclature have also been introduced text-book for the student and as one ol th< 
into the present edition. Notwithstanding the multi i The Journal of Nervous and ' K.Jan. 1876. 

plicity of text-lxvik-* on physiology, this will lose none ' Still holds it* position a< a masterpiece of lucid writ- 
of its old time popularity. The meehanical execution iny, and is, we believe, on the whole, the best book to 
of the work is all that could l>e desired. — Peninsula) . place in the hands of the student. — London & 
Journal of Medicine, Dec. 1^75. rnal-. 



ntJNGLISON {ROBLEY), M. D., 

•U Professor of Institutes of Medicine in Jefferson Medical College. Phil-adeJphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 

extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 

TEHMANN (C. O.). 

PHYSIOLOGICAL CHEMISTRY. Translated from the Becond edi- 
tion by Georoe E Day, M. D., F. R. S., Ac., edited by R. E. Rogkhs. If. P.. Professor of 
Chemistry in the Medical Department of the University of Pennsylvania, with illustration* 
selected from Funke's Atlas of Physiological Chemistry, and an Appendix ofplatei Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, cloth, $r> 00. 



B 



T THE SAME AUTHOR. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 

German, with Notes and Additions, by J CH BATON KoVJtll, M. P., with sn [ntrodu«t< ry 

Essay on Vital Force, by Professor Svmvki, JaCKbOV, M D . of the l'niver»ify of !' 
vania. With illustration* on wood. In one very hardsome octavo volume of 336 pages, 
©loth, $2 26. 



10 



HE^aY C. Lea's Publications — (Chemistry). 



ATTFIELD (JOHN), Ph.D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Sec. 

CHEMISTRY, GENERAL, MEDICAL, AND. PHARMACEUTICAL ; 

including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Seventh American edi- 
tion, revisec from the Sixth English edition by the author. In one handsome royal 12mo. 
volume of COS pages, with S7 illustrations : cloth, $2 75 ; leather, $3 25. {Just Issued.) . 
This work hasreceived a very careful revision at the hands of the author, resultingin aconside- 
r i hie increase in size, together with the addition of a handsome series of illustrations Notwith- 
standing these improvements, the price has been maintained at the former very moderate rate. 
[t is a valuable woTk for the busy practitioner, ex | variety which he 'jives is certainly well calculated to 



eluding aa it does everything that would be of iute- 
ntiflc chemist, and having a com- 
prehensive index which readers after consultation 

in it portion devoted to urinalysis and prac- 
igy. and the tests for imparities in medi- 
cinal preparations, is especially valuable to the 
practising physician. For the student it is desirable, 
for the rea-on that it is >o arranged that he may, 
'without au instructor, study the science experiiueut- 

[ a. Practitioner, March, 1S77. 
After having used it as a text-book in the laboratory 
of the PhiladelphiaOollegeef Pharmacy during tbelast 

rs, we can speak from our own experience, and 
testify to Its Intrinsic value in the instruction of the 
Student. The more we have u«ed it, Ihe more we W6T" 

with it. and (in the appearance of a new. revised. 
and enlarged edition, we take occasion to again cordi- 
ally recommend it. believing that for the practical in- 

n of pharmaceutical students in chemistry it 

superior in the English language.— Am. Journ. 
of Pharrn., Nov. 1876. 

The book, by a well arranged system, introduces the 
student into the Science of Chemistry, giving him at 
each step sufficient information to enable him to per- 
f iro experiment'' with his own bands; theexperiments 
are partly of synthetic il and partly of analytical inte- 
this way the editor succeeds admirably in 
avoi ling a dry monotonous enumeration of facts. The 



prevent the reader from petting tired. This variety. 
however, is not such as to bewilder the mind, nor are 
ihe experiments described calculated only to serve as a 
pleasant pastime. The student who reads the hook and 
executes the experiments mentioned, cannot help but 
feel deeply interested in the subject, and indeed, will, 
going through the practical work, find it a very agree- 
able recreation. — Cincinnati Clinic. Oct. 28, 1876. 

It brings up our knowledge of the subject to the pre- 
sent date, and has been enriched with numerous wood 
engravings illustrative of apparatus and modes of work. 
The arrangement of the work is admirable, and to each 
element it* more important compounds used in inedi- 
cineor pbarmaoy are given, together with both syntheti- 
cal and analytical rencti >ns. The systematic analysis 
of compound*, substances or fluids is also treated of, 
and copious tables are given showing the modes of sys- 
tematically separating tlm different elements from one 
another. — Canada Med. and Surg. Journ , Nov. 1876. 

As a compact manual of the general principles of the 
science and their applications in medicine and phar- 
macy, it has no rival, and the frequent and thorough 
revision it receives keeps it in all respects up with the 
times The American edition, which covers the United 
States Pharmacopoeia, is prepared under the author' 
supervision — Boston Journal of Chemistry. Nov 1^76. 

Admirably a lanted to the use of medical students.— 
Atlanta Med. Journ. .Oct. 1876. 



F 



OWNES [GEORGE), Ph.D. 



A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. With one hundred and ninety-seven illustrations. A new American, from the 
tenth and revised London edition. Edited by Robert Bridges, M. D. In one large 
royal 12mo. volume, of about 850 pp.; cloth, $2 75; leather, $3 25. 
This work is so well known that it neems almost f >ther work that has greater claims on the physicia d, 
■r us to speak about it. It has been a pharmaceutist, or student, than this. We cheerfully 
favorite text-book with medical students for years, recommend it as the best text-book on elementary 
H ,l its popularity has in no respect diminished, -jheraistry, and bespeak for it the careful attention 
Whenever we have been consulted by medical stu- >f students of pharmacy.— Chicago Pharmacist, Aug. 
Li has frequently occurred, what treatise on j 186.9. 
v , hey should procure we have always re- w|n C0Qt} a8 heretofore< tohold the flr8t ran * 

otnmended Fownes , for we rega ■>***"**£**'«■> w a text-book for students of medicine.-Cftf™* o 
T ,.re is uo work that combines so many excellen- . , Fxamintr An- 1R8P 
nvenient size, not prolix, of plain M ' a - "'***' An * 18bP - 
liotlon, contains all the most recent Fownes's Chemistry has for many years maintained 
in I is of moderate price.— Cincinnati 



red. "Repertory, Ang. 1869. 
Here in a new edition which has been long watchec 
of ohetnlstry, I n its new garb 

and nnder tb Utorshipof Mr. Watts, n has resumec 

i . .,!,i pi tee as the moat successful of text-books.— 
, Medical GfaeeUe, -Ian. i, 

iddltiom bare been made, especially in the 
nent of organ f, and we know of no 



Foremost rank as an authority, a tid now it comes to 
us in iis tenth edit! >n, tbor nghly rejuvenated and 
fully ii]> to the present demand of the student Bad 
practitioner. Any one who studies the work carefully 
will be surprised al the perfect oess of Its method, the 
ooooiseness of its language, and the lucidity >>f the 
Ideas advanced. Th b latter is saying a ureal deal for 
chose parts of the Relenca generally considered the 
■ruse. — tf. y. Mad. Record, Sept. I, lSb'9. 



U<> WHAN {JOHN E.),M. I). 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 

by C. L. Bi.oxam, Professor of Praotieal Chemistry in Kind's College, London. Sixth 
A iip-rii-nn. fro to the fourth an. I rev bed English Edition. In one neat volume, royal 12mo. , 
pp. 161, with nninerou i 1 1 DJ t rat loi ejol h, -2 25. 

DT THR BAMB AUTHOR. {LaMy leeueAV) 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLTTDlVfl 

ANALYSIS. Sixth American , from the -ixth and revised London edition. With nuintr- 
ouh Illustrations. In one neat vol., royal 12m.,., cloth, $2 26. 



II ROLOG I iry Applied to 

i \ r»*. sod to Hanoi 

. i K B .'on s iom I n two 



•v.. volnincK, with 
loth, |6 00. 



ooo wood 



Henry C. Lea's Publications — (Chemistry). 



11 



T>LOXAM (C. L.), 

*-* Professor of Chemistry in King'' 8 College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 

don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- 
tions. Cloth, $4 00; leather, $5 00. (Just Issued.) 
It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- 
sive for those studying the science as a branch of general education, and one which a student 
may use with advantage in pursuing his chemical studies at one of the colleges or medical schools. 
The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders 
the work especially useful to those who are being educated for employment in manufacture. 

We have in this work a complete and most excel- 1 titioners who wish to review their chemistry, or have 

lent text-book for the u-e of schools, and can heart- | occasion to refresh their memories on any point re- 

ily recommend it as euch.— Boston Med. and Surg, lating to it. In a word, it is a book to he read by all 

Journ., May 28, 1S74. who wish to know what is the chemistry of t he pre- 

Theaboveis the Htleofa work which we can most »ent day.-^wertodw PrmctiHoner, No*. 1873. 



conscientiously recommend to students of chemistry. 
It iR as easy as a work on chemistry could be made, 
at the same lime that if presents a full account of that 
science as it now stands. We have spoken of the 
work as admirably adapted to the wants of students ; 
It is quite as well suited to the requirements of prac- 



Prof. Bloxam poseef nenlly the inestima- 

ble Sjifi of perspicuity. It is a pleasure to read bifl 
books, for be is capable of making very plain wl at 
other authors frequently have lett very obeoare. — 
Va. Clinical Record, Nov. 1878. 



flLO WES (FRANK), D.Sc, London. 

^ Senior Science- Vaster at the Hicjh School, Neivcnstle-under Lyme, etc. 

AN ELEMENTARY TREATISE ON PRACTIC A L CHEMISTRY 

AND QUALITATIVE TNORGANIC ANALYSIS. Specially Adapted for Use in the 
Laboratories of Schools and Colleges and by Beginners. From the Second and Revised 
English Edition, -with about fifty illustrations on wood. In one very handsome royal 
12mo. volume of 372 pages : cloth, $2 50. (Note Ready.) 

and intellig r ble. The work is unincumbered with 
theoretical deductions, dealiug wholly with the 
practical matter, which it is the aim r f this compre- 
hensive text book to impart. The accuracy of the 
analytical methods are vouched for from the fact 
that they have all been worked through by the 
author and the members of his c ass. from the 
printed text. We can heartily recommend the work 
to the student of chemistry as being a reliable &*d 
comprehensive one. — Druggists' 1 Advertiser, Oct. 
15. 1S77. 



The methods are modern, and the present approv- 
ed system of nomenclature aud notation are used 
exclusively — facis which especially commend the 
book to new students in qualitative analysis.— C/u'- 
COffo MM. Joum. and Examiner, Oct. 1S77. 

It is short, concise, and eminently practical. We 
therefore heartily commend it to studen s, and espe- 
cially to those who are obliged to dispense with a 
master. Of course, a teacher is in every way desi- 
rable, but a good degree of technicil skill aud prac- 
tical knowledge cau be attained with uo other 
instructor thau th<* very valuable handbook now 
under consideration.— St Louis Clin. Record, Oct. 
1S77. 

The work is so written and arranged that it can be 
comprehended by the student without a teacher, aud 
the descriptions and directions for the various work 
are so simple, and yet coucise, as to be interesting 



With this manual before him the advanced stu- 
dent cau undertake experiments without the assist- 
ance of the professor. The aim of the author haa 
been to make it as simple as possible, and for this 
purpose he has abandoned many technical phrases, 
and substituted therefor simply paraphrased terms. 
— Nashville Med. and Surg. Journ., July, 



T>EMSBN{IRA). M.D., Ph.D., 

-*-*' Pm/essor of Chemistry in the Johns Hopkins University, Baltimore. 

PRINCIPLES OF THEORETICAL CHEMISTRY, with special reference 

to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
232 pages: cloth, $1 50. (Just Issued.) 

For such stud v, essent'al for exactness iu scieuiiftc ' combination and deeomposit r on. and the various theo- 
tbouc;lit, Prof. Remeen'8 book supplies valuable ma- 
terial. it is uniformly dear and logical Tueauthor 
seldom overstrains a theory, and iu several cases, as 
for iustauce, in his rem irks en atomicity (p ->!, >t 
■<<■'/. i points out difficulties which are too often over- 
looked. He has made many t binge ea-y of compre- 
hension, which are generally very ditficult, and al- 
together his book will be real treasure to earnest 
Btudenta —London Lane t, Aug. is 7. 

This volume is devoted to the principles upon which 
the theoretical structure of modern chemi try is based, 
and as such it is ;i \ cry valuable addition to our litera- 
ture, insomuch :ts it, discusses, in a clear and comrre- 
heustve manner, the various laws governing chemical 



ries which have been advanced for explaining an- 
nouinTii facti*. In oar opinion, the work will prove ro 
be a valuable a : d to the chemical student wl 
familiarize himself with the theories of the science tbat 
have led to m <ny important discoveries. — Atn. Journ. 
•f Pliarm., .June. 1S77. 

It is an admirable presentation of the lea 1 : 
trin^s Of modern cheuii-ry If Rome RUQJ< 

briefly treated, it i~ simply because so little 

known about them, and the author DM bad the rs'e 

good sense not to lumber hi* pages with unprofitable 

speculations and mere •• gruesBOE at the truth "- 
Journ. of Chitn.. May. ^77. 



\\r-OHLER AND FITTIG. 

fr OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- 

ditions from the Eighth German Edition. By Ira EtBMBBV, M D., Ph.D., IV 

Chemistry and Physics in Williams College, Mass. In one handsome volume, royal |] 
of 550 pp., cloth. $3. 
As the numerous editions of the original attest, this work is the leading text-book and B( 
authority throughout Germany on its important and intricate subject — a position won for it hv 

the clearness and conciseness which are its distinguishing oharaoteristles. The translation hsi 

been executed with the approbation of Profs. Wohler and Plttig, and numerous tdditioi 
alterations havo been introduced, so as to render it in ct on I !e\e! with the most 

advanced condition of the science. 



12 Henry 0. Lea's Publications — (Mat. Med. and Therapeutics). 
pARRLSH {EDWARD), 

Late Professor of Materia Mtdica in the Philadelphia College of Pharmacy . 

A TREATISE ON PHARMACY. Designed as a Text-Book for tie 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae ana 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one 
handsome octavo volume of 977 pages, with 280 illustrations; cloth. $5 50; leather, $6 50. 
i Lately Issued.) 
The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au 
thor, have postponed the preparation of this new edition beyond the period expected. The notes 
and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegand, 
who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- 
ence which have been introduced during ,he last ten years. It is therefore hoped that the new 
edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard 
text-book and work of reference for all engaged in the preparation and dispensing of medicines. 
Of l>r Parrish's great work on pharmacy it only an honored place on oar own bookshelves. — Dublin 
r< mains to be -aid that t lie editor has accomplished Med. Press and Circular, Aug. 13, 1S74. 

We expressed our opinion of a former edition in 
terms of unqualified praise, and we are in no mood 
to detract from that opinion in reference to the pre- 
sent edition, the preparation of which has fallen into 
competent hauds. It is a book with which nopharma- 



I:!- work so well as to maintain, in this fourth edi- 
tion, [be higb (standard of excellence which it bad 
attained in previous editions, under the editorship of 
iU accomplished author. This has not been accom 
■ i without much labor, and many additions aud 
Improvements, involvingchangeain the arrangement ci s t" Van dispen^ and "from which no physician can 
i i he several parts of the work, and the addition ot fiiil to derive , nnch j n f ormaf j on f value to him in 



practice. — Pacific Med undSurg. Journ., June, '74. 

With these few remarks we heartily commend the 
work, aud have no doubt that it will maintain its 
old reputation as a textbook for the studeut, and a 
work of reference for the more experienced physi- 
cian aud pharmacist. — Chicago Med. Examiner, 
June 1.3, 1S74. 



much new matter. With the modifications thus ef- 
fected it constitutes, as now presented, a compendium 
of the science aud ait indispeusable to the pharma- 
cist, aud of the utmost value to every practitiouer 
of mediciDe desirous of familiarizing himself with 
the pharmaceutical preparation of the articles which 
« i ibes for his patients.— Chicago Med. Journ., 
July, ls74. 

The work is eminently practical, and has the rare | Perhaps one, if not the most important book npon 
merit of being readable and interesting, while it pre- - pharmacy which has appeared in the English Un- 
serves a atrictly scientific character. Thewholework guage has emanated from the transatlantic press. 
i elects i lie greatest credit on author, editor, and pub- "Pa Irish's Pharmacy" is a well-known wort on this 
lisher 1 1 will convey some idea oft he liberality which side of the water, and the fact shows us that a really 
n bestowed npon its production when we men- useful work never becomes merely local in its fame, 
tion that thereare no less than 280 carefully executed Thanks to the judicious editing of Mr. Wiegand, the 
Illustrations. In conclusion, we hear.ily recommend posthumous edition of "Parrish" has been saved to 
the work, not only to pharmacists, but also to the the public with all the mature experience of its au- 
ide of medical practitioners who are obliged ' thor. and perhaps none th» worse for a dash of new 
to'compouud their own medicines. It will ever hold blood.— Loud, fhartn. Journal, Oct. 17, 1S74. 



QTJLLE {ALFRED), M.D., 

O Professor of Theory and Practice of Medicine in the University of Penna. 

THERAPEUTICS AND MATERIA MEDIC A; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 
Fourth edition, revised and enlarged. In twolarge and handsome 8vo. vols, of about 2000 
pages. Cloth, $10; leather, $12. {Lately Issue,/.) 
The care bestowed by the author on the revision of this edition has kept the work out of the 
market for nearly two years, and has increased its size about two hundred and fifty pages. Not- 
withstanding this enlargement, the price has been kept at the former very moderate rate. 

It is unnecessary to do much more than to an- of the present edition, a whole cyclopjedia of thera- 
u .uiic- ili.- appearance of the fourth edition of this peutics. — Chicago Medical Journal, Feb. 1 s 7 ."> . 
w.-ii known and exoMlent work.— Brit, and For. The magnificent work of Professor Stille la knowa 
Med.-Ohi T /.'• view, Oct l v 7... wherever th.' English language is rend, and the art 

Who desire B <• .mplete work on therapeutics of medicine cultivated ; known so well that n 



and materia medics for reference, in eases involving 

tions, as well as for Information 

concerning remedial agents, i>r Btilld'sis "par >■'- 

the work. The work being out of print, by 

d ,,i (brmer editions tbeantkor has laid 

a nndi t renewed obligations, by the 

on, Important additions, and timely re- 

. ; iv supplemented by any 

other In the English language, If in any language. 

, i\ execution bands ly sastains the 

skill and good taa f the publisher.— 

■. | and Surg Journal, Dec 1871 

Dr. StlUe i [real work 

,• ,, ,,. .1 but H- leat efug 

impart d with the dlsertmUatlng 

ibowo by it- antbor inn..' .lis 

i whirh renders n a ti net- 

tbeeJok-i ion 



miuiii of ours eould brighten its fame, and no unfa- 
vorable criticism coiii. l tarnish Its reputation. — Phil' 
adeiphia Med. Times, i>.-c. 12, ks74. 

The rapid exhaustion of three editions aud the uni- 
versal favor With which the work has I n received 

by the medlqaj profession, are sufficient proof of its 

excellence as a repertory of practical and u-oftil in- 
format i "ii for | ho physician. The edition before 'is 

fully sustains this verdict, as the work has been care- 
ful J y revised and in BODI6 portions rewritten, bring- 
ing it Up to the present lime by the admission of 
chloral and croton chloral nitrite <>!' amyl, bichlo- 
ride of methylene, methyllc ether, lithium com- 
pounds, gelsemlnnm, and other remedies. — Am. 

jm/rii of Pbarnaey, Peh. IMS. 

We cm hardly admit Unit it has a rival in the 

multitude of Its citations and the rhlaeai of it m re- 

.i,/i. Praetitioner, ..,.,, r ,.|, t Q to clinical histories, and we must assign it 

■ nlaoi in the physician's library; not, Indeed 



, , edition "Stille'i fully representing the present state of knowledge in 

,,,. of ii,.. el '■• pharmacodynamics, but as by far the most complete 

raoaan treatise ap be clinical and practical side .x ihe 

,i by .t i.< i work kn the Ian- question — Aoatvti Mai. and. Surg Journal, flat . «j 

lie i wo rolnmas i^:i. 



Henry C. Lea's Publications — ( Mat. Med. and Therapeutics). 13 
UTILLE (ALFRED), M.lh LL.D., and IfAiSCR [JOHN J/.). Ph.D.. 

O Prof of Theory and Practice of Clinical - L *^~ Pr.f.ofMat Med. and Bat in Phil a. 

Med. in Umv. of Pa. Coll. Pharmacy, 8*cy to tht A 

Pharmaceutical Aw da 

THE NATIONAL DISPENSATORY: Embracing the Chemistry, Botany, 

Materia Medica, Pharmacy, Pharmaeorlyo amies, and Therapeutics of the Pharmaco- 
poeias of the United States an<l Great Britain. For the Use of Physicians and Pharma- 
• ceutists. In one -an Isome octavo volume, with numerous illustrations. [Preparing) 
The want has long been felt and expressed of a work which, within a moderate eon 
should give to the physician and pharmaceutist an authoritative exposition of the Pharmaco- 
poeias from the existing standpoint of melicil and phirni iceutical science. Fo" s°veral 
t lie authors have been earnestly engaged in the preparation of the present volume, with the 
hope of satisfying this want, and their labor* are now sufficiently advanced to enable the pub- 
lisher to promise its appearance during the coming season Their distinguished reputation in 
their respective departments is a guarantee that the work will fulfil all reasonable expectation as 
a guide in the selection, compounding, dispensing, and medicinal uses of dru<rs complete in all 
rtspects, while conven'ent in size, and carefully divested of all unnecessary and obsolete il itter. 

filARQUFTARSOX ( ROBERT). M.D., 

■*- Lerturer an Materia Medina at St. Mary's Hospital Medical School. 

A GUIDE TO THERAPEUTICS. Kdited, with Additions, embracing 

the U. S. Pharmacopoeia. By Fran'k Woodhury, M D. In one neat volume, rojal 
12mo. volume of over 400 pages : cloth, $2. (Noio Ready.) 
The object of the author has been to present in a compact and compendious form the the- 
rapeutics of the Materia Medica, unincumbered hy botanical and pharmaceutical details. The 
volume is thus emphatically a work for the medical student, to aid in hi? acquiring a clear and 
connected view of the subj* ct in its most modern aspects; and for the busy practitioner who 
may wish to refresh his memorv. Under each article, in parallel columns, are given its phy- 
siological and therapeutical actions thus enabling the reader to take in at a glance the essential 
facts with respect to each remedy, ami numerous formulae are givtn as examples of their prac- 
tical use. Considerable additions have been introduced by Dr. Woodbury, who has made 
numerous changes to adapt the work to the wants of the American student, introducing all the 
preparations of the U. S. Pharmacopoeia, and many of the newer remedies. 

This little volume is an earnest effort to advance manner, that it deserves careful study by every stu- 
the iuteiests of intelligent therapeutics. In a mode- deut and youDg practitioner. — Cincinnati Clinic, 
rate compass we tiud ihe established facts concerning Jan. 12, 187S. 

the physiological and I therapeutical .actions of rente- M pei . sons who Earned therapeutics before 
dies. I he corre-pondmsc effects of different remedies „ ie physio i ogical action of remedies was taught to 
in health and di -ease are presented in parallel col- 6ludents fiad it difficult to discover the bearing of 
nmus. 1 his arrangement impresses us very favor- physiological action on therapeutic employment 



ably, as both convenient and ctlculated to stamp 



from ordinary text hooks. Dr. Farquharson ha- mo»t 



the facts noon the memory.- We d > not know of an iDgenioUtily ; hown ir hv pr j Et ing the two in parallel 



eojial on m her of pages in one work that con ains to 



columns and corresponding paragraphs, so ibat, by 



la of the student anything near as valuable ruiiuing tl , e eve dowu tlie left-hand side of a | 
an account ot those subetAuee*. We can cordially t tne physiological actions of a drng, and on the 
commend this work to the medical student at the best rigbt-band the therapeutical uses, while, by running 
introduction to the study ot larger and more elabo- U straight across the page, we at once perceive the 

relations ot the oue to the other. On this account, the 



rated treatises —Detroit Lancet, Jau. 1S7S. 

An excellent feature of Dr Farqtiharson's Guide, work i> likely to be useful. not only to students pre- 

and oue whicii will commend it to all earue.-t stu- piringfor their examinations, but to those medical 

dents, is the arrangement, in tahulir form, of the va- meu, also, who are well acquainted with larger 

rious officinal preparations and their dose, so that books on the same subject, but experience the dirti- 

thoy may be readily committed to memory This ulty, already meutioued, of seeing the relations 

handbook is so well arranged, and presents the well between the actions aud u>e of remedies. — Tlf 

established facts of therapeutics in so impressive a London Practitiontr, January. 



QRIFFITH {ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Pre por- 
ing and Administering Officinal and other Medicines. The whole adapted to Physioiai > and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, tv Job* M 
Maisch, Professorof Materia Medica in the Philadelphia College of Pharmacy. Inone large 
and handsome octavo volume of about S00 pp.. c l., $4 60; leather, $5 50. 
As a comparative view of the United States, the British, the German, and the French 
Pharmacopoeias, together with an immense amount of nnofficinal formulas, it affords to the prac- 
titioner and pharmaceutist an aid in their daily avocations nftt to be (band elsewhere, while three 

indexes, one of "Diseases and their Remedies," n,ie „t Pharmaceutical BTam leneral 

index, afford an easy key to the alphabetical arrangement adopted in the text. 

To the druggist a good formulary la simply indie- j a more complete formulary than It la Is Iti 
pensable, and perhaps no formulary has been no >re out form the pharmacist or pays hardly 

extensively used than the well-known work before desire To the Srsi some such work is lad 
as. Many physicians have to officiate, also, as drug- ble, and it Is b 

This is true especially of the country physi- w |,„ eorop mads Uii own m di. ;' what 

cian, and a work which shall teach him the meant: is contained in the ' ought to 

hy which to administer or combine his remedies In mltted to memory by si 
the most efficacious and pieasmit manner, will ti v- ;i help to phyxiciana II will he found Ini 
ways hold its place upon his shelf. A form alary of ' ., n i dcabtlms w II make I » wai 
this kind is of benefit also to the city ohysiolan In ., 
largest practice.— Cincinnati llinte, Peb. 81, 1874, —T'i, American Practiti 



u 



Henry C. Lea's Publications — (Pathology, &c). 



JJ7EN WICK (SAMUEL), M.D., 

-*- riant Phyeieian to the London Bogpitatm 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Editior. With eighty-four illustrations on wood. 

In one very handsome volume, royal 12mo., cloth, $2 25. (Just Issued.) 
of the many snide-books on medical diagnosis, 
claimed to be written for the special instruction of 

s, t hi.- is the best. The author is evidently a 
well-read aud accomplished physician. and he knows 
how to teach practical medicine. The charm of sim- 
pl iciiy is not the least lnt»restingfeetnrein the man- 
ner io which Dr. Feufl ickconvej^ iusti -notion. There 
a re few books of this >ize ou practical medicine that 
contain so much and convey it so well ;<s the volume 
before u> [tis a book we can sincerely recommend 
to the student for direct instruction, aud to the prac- j 
titioner as a ready and useful aid to his memory. — , 
Am. Jour a. of Syphilography, Jan. 1874. | 



It covers the ground of medical diagnosis in a con- 
ci>e, practical manner, well calculated to assist the 
student iu forming a correct, thorough, and system- 
atic method of examination and diagnosis of disease. 
The Illustrations are numerous, and finely executed. 
Those illustrative of the microscopic appearance of 
morbid issue, &C . are especially clear and distinct. 
— Chicago Med. Examiner, .Nov. lii:>. 

So far superior to any offered to students that the 
colleges of this country should recommend it to their 
respective classes. — N. 0. Med. and Surg. Juurn., 
March, 1S74. 



(IRE EN (T. HENRY), M.D., 

*~* //• eturer on Pathology and Morbid Anatomy at Charing-Oro-ts Hospital Medical School. 

PATHOLOGY AND MORBID ANATOMY. Second American, from 

the Third and Enlarged English Edition. With numerous illustrations on wood. In one 
very handsome octavo volume of over 300 pages, cloth $2 75 {Jvst Issued ) 
Th »se not acquainted with this text book ought to | author's own seciions and drawings. We can only 

repeat what we have said before, that 



• have always thought that for the average 
doctor this work was much more useful than the larger 
treatises. lutoit is condensed such knowh dgetogain 
which, elsewhere, would require great labor and 
wide leading. For students aud practitioners full 
of cares, it is particularly valuable. In this edition 
the general h gh character of the work is maiutaiued, 
the new cuts are fully up to the standard of those 
used before, which were excellent, the execution of 
the work a' the hands of the publisher is faultless. 
—Qhlaago M*d J num. and Exam , Feb 1S77. 

Altogpttpr. this is the best short manual of morbid 
anatomy in the Euglish language, and we regret that 

OS a ad t he character of our contents forbids a 

more extended notice The airangement and choice 

of subjects, the clearness and comparative thorougb- 

• '-merits make it very satisfactory. We 

totally pleased with th« appearance of the 
wood cut-, most of them made for this work after its 



know of 

nothing in. th» way of a brief manual, superior to it 
in the English language. It may be safely and heartily 
commended to students, especially of morbid anat- 
tomy. — Jottm. of Hr.rvov.8 and Me nlal Distane, Oct. 
1S76. 

This useful and convenient manual has already 
reached B third edition, ami we are glad to find that, 
a, though it has grown somewhat larger, it still remains 
a little book, and we are inclined to forgive the increase 
in size on account of the valuable additions which the 
author has made both to the printed matter and to the 
illustrations. The new illustrations, drawn by Mr.Col- 
lings from preparations by Dr. Green himself, are very 
good, ami (he care and trouble expended bj the author 
in the preparation of this edition will no doubt increase 
the popularity of his book, great though it already is. — 
The London Practitioner, Feb. 1876. 



W HATTO OBSERVE ATTHE BEDSIDE AND AFTE1 
Death in Medical Cases. Published under th( 
authority of the Loudon Society for Medical Obser- 
vation. From the second London edition. 1vol. 
-oyal I2mo. cloth. *1 00. 

CHRISTISON'S DISPENSATORY. With copious ad- 
ditions, and 818 lurtro woo^-insrravinarn By R 
-kkld Grifpith, M. D. One vol. Svo., pp. 100i 
cloth. MOO. 

CARPENTER'S PRIZE ESSAY ON THE USE Ol 
alcoholic Liqvors t.v Health and Disease. Nev- 
edition, with a Preface by f> F COHD-iE, M.D., auc 
explanations of scientific words. In one neat )2mc 
volume, pp. 178, cloth. ttO oentS 

LAB <>F PATHOLOGICAL HISTOLOGY. 
Translated, with Notea and Additions, by JoflBPB 



Leidy, M. D. In one volnme, very large imperial 
quarto, with 320 copper-plate figures, plain aud 
colored, cloth. $4 00. 

LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological, Etiological, and Therapeu- 
tical Relations. I n two large and handsome octal o 
volumes of nearly 1500 pages, cloth. $7 00, 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol 8vo., pp. SOO, cloth. *3 50 

BARLOWS MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. G'ondik, 
M D 1 vol Svo.. pp 600. cloth. *2 AX) 

TODD'SCLINICAL LECTURES ON CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pages, 
cloth. *2 fiO. 



s 



J) 



8 



MED- 

In one 



TURGES [OCT A VIUS), M.D. Cantab., 
Fellow of t*t Royal Collage of Phytdciane, Ac dr«, 

AX [INTRODUCTION TO THE STUDY OF CLINICAL 

[CINE. Being a Quids to the Investigation of Disease, for the Use of Students 

D&ndtome ISmO. volume, Oloth, •? I 2:>. [Lately Issued.) 

.1 VIS NATBAN 3\ 

■ ■/ Prinoiplet "„d Praettoe of Medicine, etc., In Chicago Med. Ootleg*. 

CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; 

i sing ,i oolleotion <>f th<- Olinfoal Leotnaft delivered in the Medical Wards of Mercy Hos- 
i >ita), Obioigo. BdHed by Fbarb U. Davis, M D. Beoond edition, enlarged, in due 
bandsoine royal ISmo. volume. Clovfa, $l 75. (Lattly tutted.) 

T0KES ( WILLIAM), M.D. % D.C.L., F.R.S~, 

Btgius Prrfeeeor nf Phytic in thi <'•">■ of Dublin, Ac. 

LECTURES ON FEVER, deliveretUn the Theatre of the Meath Hos- 
pital ;in<i Oonnty of Doblin [nfirmary. Edited i>v ,F'.u\ William Moors, M.D . Assistant 
Ian to the l I Paver Hospital. In one neat ootavo volume. Cloth, $2 00. 

(.fa, 



Henry C. Lea's Publications — (Practice of Medicine). 



1.3 



ipLINT (AUSTIN), M.D., 

■*- Professor of the Principles and Practice of Medic4.ne in Belleirue Med. College, N. Y. 

A TREATISE ON THE PRINCIPLES AXD PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 

edition, revised and enlarged. In one large and closely printed octavo volume of about 1 100 

pp. ; cloth, $6 00 ; orstrongly hound in leather, with raised bands, $7 00. U.atehj Issued.) 

By common consent of the English and American medical press, this work has been a.-signed 

to the highest position as a complete and compendious text-book on the most advanced condition 

of medical science. At the very moderate price at which it is offered it will be found one of the 

cheapest volumes now before the profession. 

This excellent treatUe on medicine has acquired [ deuts and a book of read 7 reference for practitioners, 
far itself in the raited states a repntatinu similar to The foroe of Its logic, ir.s .simple and Dractical te*ch- 
that enioyed in England by the admirable lectures iog*, have left it without a rival iu the. field 
of 8ir Thomas Watson. It may notpoHsess the same Med Record, Sept 15,1874 

charm <»f style, but i» has like solidity, the fruit of Flint's Practiceof Medicine has become so fixed la 
long and patient observation, and presents rindred Us position a* an American text book that lit; 
moderation and eclecticism. We have referred to begilid beyond the announcement of a u-w edition, 
ruanyof the most, inportant chapters, aud find there- ; It may. however, be proper to sa.y that the author 
vision spoken of in the preface is a geuuine one, and nas iinpr oved the occasion to introduce the latest 
that llieaulhorhasveryfairlybroughtuDhismatter contributions of medical literatui with tbe 

to th« level uftheknowledgeof the preneut day. The results of his own continued clinical observations. 
work hasthisgreat recommendation, that it in moue , Not so extended as many of the standard w 
volume, aud therefore will not he so terrifying to the j pTa etice, It still is sufficiently complete for all ordi- 
student as the bulky volumes which several of our na ry reference, and we do not know of a more con- 
Ensrllsh text-books of medicine havedeveloped into, j v< , nie nt work for the busy general prac iiioner.— 

— British and Foreign Med.-Chir, Rev., Jan. 1876. Cincinnati Lancet and Observer, June, 1878. 

It is of course unnecessary tointroduce or eulogize Prof Fiint, in the fourth edition of his great work, 
this now standard treatise All the colleges recom- | has performed a labor reflecting much credit upon 
mend it as a text-hook, and there are few libraries 1 h'mself,and conferringa lastingbenetit upon the pro- 
i n which one of its editions is not to be found. The j fessioa. The whole work showsevidence of thorough 
present edition has been enlarged aud revised to bring ; revision, so that it appears like a new book writteu 
it up to the author's present level of experience and expressly for the times For thegeneral practitioner 
reading. Hisownclinical studies and the latest con- \ aud student of medicine, we cannot recommend the 
tributions to medical literature both in this country j book in too strong terms — A". Y.Med. Jour ..Sept '73. 
and in Europe, have received careful attention, so , it i K given to very few men to tread in the steps of 
that some portions have been entire yrewritten and Austin Flint, whose single volume on medicine, 
about seventy pages of new matter have been added a.ough here and there defective, is a masterpiece of 

— Chicago M*d Jovrn., June, 1S/.5. l„ cid condensation and of general grasp of an enor- 
Has never been surpassed as a text-book for stu- j moui-ly wide subject — Land. Practitioner, De.c. '78. 

Y THE SAME AUTHOR. 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. (Just Issued.) 



B 



This little work comprises a number of essays written I etiology, prophylaxis, and therapeutics, and divine de- 

at various times for medical journals and eooieties. His *ign, as exemplified in the natural history of flj 

unnera wary to say aughthn regard to the stylo in which , A more sngiestive collection of topics it would be dlfll- 

theyare written, for Dr. Flint is familiar as a house- cult to conceive The assays on conservative medicine 

hold word to the profession. His name is a guarantee are peculiarly valuable. The author in these take* :i 

thajt the subjects are treated in a masterly manner. The , very common-sense view of the treatment of 

fill lowing subjects are discussed: Conservative medicine, 1 and shows the necessity of " confer vinjt" to the fullest 

as applied to therapeutics and hygiene, medicine in the extent the strength of the system in order to devise th 



nt. and tbe future, alimentation in di 
ease, tolerance of disease, on the agency of the mind in 



best results from the vu medicatrix nuiurai.—I'tniiisulu.r 
Mil .Tnurn , Oct L&71. 



VSTA TSON (THOMAS), M. D., frc. 

f LECTURES ON THE PRINCIPLES 



AND PRACTICE O* 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
tions, by Henry Hartshorne, M.D., Professorof Hygiene in the University of Pennsyh a- 
' nia. In two large and handsome 8vo. vols. Cloth, $ft 00 ; leather, $11 00. {Lately Published.) 



Tt is a subject for congratulation aud for thankful 
nessthat Sir Thomas Watson, during a period of com- 
parative leisure, after a long, laborious, and most 
honorable professional career, while retaining full 
ion of his high mental faculties,* should have 
employed tbe opportunity to submit his Lectures to 
,t more thorough revision than was possible during 
tho earlier and busier period of hie life. Carefully 
la review some of the most intricate and im- 
portant pathological and practical questions, there- 
suits of his clear insight no 1 |udgm< nt are 
now recoi dedfor the benefit of mankind, in 
which, for precision, vigor and u ^ry>. ha s 
rarely i. >,and never surpassed The re- 
vision has evidently beeD most carefully dome, and 
the results appear In almoel every page — Brit. Med. 

Jnnrn.. Oct. I 1. 1871. 

The lectures are so well known and so justly 

T)UNGLISON, FORBES, TWER DIE, AND OONOLLY. 

THE CYCLOPAEDIA OF PRACTICAL MEDICINE: oompi 

Treatises on the Nature and Treatment of Diseases, Bft&terifl I 

Diseases of Women and Children. MediealJurispradei In fear targe super r 

octavo volumes, of 3254 double-columned ; 1 ;]y and handsomely bound 

$15; oloth, $11. 



appreciated, that it is scarcely necessary to do 
more than call attention to the special adv 
of the last over previous editions The author's 
1 aw combtoatioi of greal scientific attainmei 
bined with wonderful forensic eloqueoee has. 
extraordinary Influence over the last two generations 
of physicians Hiscliuical descriptions of m 
eases have OO' 1 !.. 

at least his work will live Ion*!; in the fatun 
work will he sought by all who appri 
book. — Amer i graphy. Jul] 

Maturity ef y, ars, axt< Delve observation, profound 
atiouous eathurili - 
hiiied t< giveu*iotl "ii a model of pro- 

■\ u t y i a 

the mode of communication. Bui 1 1> i - 

no eulogium 01 0\m.—-Ghi 

1ST 2 



Ifi 



Henry C. Lea's Publications — (Practice of Mi dtcine). 



DRISTO WE [JOHN SVER), M.D ., F.R.C.P., 

J—J Phyxicim and Joint Lecturer on Medicine, St. Thomas's H'^jdtol. 

A MANUAL OX THE PRACTICE OF MEDICINE. Edited, with 

Additions, by James H. IIu chinson, M.D., Physician to the Penna. Hospital. In one 
handsome octavo volume of over 1 100 pages : cloth, $5 50; leather, $fi 50. [Just Ready.) 
In the effort of the author to render this volume a complete and trustworthy guide for the 
student and practitioner he has covered a wider field than is customary in text-books on the 
Practice of Medicine, and has sedulously endeavored to present each subject in the light of the 
..dern developments of observation and treatment. So much has been done of late years 
to enlarge our knowledge of disease by improved methods of diagnosis, and so many new agen- 
cies have been called into service in treatment, that a condensed and compendious work, tho- 
roughly on a leve 1 with the advance of medical science, can hardly fail to prove of value to the 
-ion. In the present volume this has been so completely accomplished that the Editor 
has found it necessary only to make such additions as seemed requisite to present in more detail 
matters in which the practice of this country differs from that of Europe. 

Dr. Brie owe lia« long been before the profesn'on we could wish a fuller discussion and greater detail 



a* :iu al'le tliiuker and writer ou profesfiooal Rub- 
Bia present work is second to none of its 
kind, the p<trt ou disease* of the nervous system 
being, perhaps, the most deservine of praise. It is 
eminently readable, both in matter and priut, aud 
folly de-erves the success it is sure to obtain.— 

Med. Jmrn. Oct. 1S77. 
The treaimeut of the various diseaeesisadmirably 
Mutinied up, and we pronounce Dr. Brist->we's book 
t -lie °miueutly practical on this subject A fair 

9 ijiven to the dietetics of disea-e and we are 
glad thai Ibis BUbject is receiving more and more 

id in the w >rks on medicine We give the 
.-. a h »r our hearty congratulations, and his book our 
best commendations and wi.-h it nil success. — Land. 
M l. Times and <?az.,Sent i">, 1^77. 



in relation to many snbjec;s, we are constrained t 
say thaf, what has been said has been well said, and 
the book is a fair reflex of all that is cert*inly 
known on the subjects considered. — Ohio Med Re- 
corder, Jan. 1S77 

This portly volume is a model of condensation. 
In a style at once clear, interesting, and concise, Dr. 
Bristowe passes in review every conceivable subjecf 
connected with the practice of medicine. Those 
practitioners who purchase few books will find this 
a mo! t opportune publication, because co many top- 
ics Dot usually embraced in a work on practice are 
adequa ely handled. The book is a thoroughly g><>d 
one, aud its usefulness to American readers has been 
, increased by the judicious noies of the Editor. — 
Cincinnati Clinic, Jan 7, 1S77. 



Upon the while, we know of no work which we The above is an entirely new work on the practice 
co>ild more confidently recommend to the student or of medicine. From the widely known aud well earned 



actiti >ner, intending a review of tbe field of 
theory aui practice, than this book of Dr. Bris- 
\W thus com nend it, because the vast ar- 
ray of facts pertaining to the practice of medicine, as 
i' i- to day, are here pre-^en ed ably, and with that 
insthod, order, and perspicuity which, in all depart- 
t education, distinguish the lessons of an ac- 
• and profitable teacher —CMcag > Med. 
J,, urn. a nd Examiner, Aug. 1877. 

An Immense amount of information has been com- 
into this volume. Every pasre is character- 
ized by the utterances of a thoughtful man. Wliil 



ipntation of the an hor, this work is entitled to the 
highest consideration. It is eminently practical and 
contains the most recent views on tbe pathology and 
treatment of diseased conditions. We cannot com- 
mend it too highly. —Canadi Lancet, Jan. 1, 1877. 

Anyone who wants a good, clear, condensed work 
upon Practice, quite up with the most recent vows In 
pathology, will find this a most valuable work. The 
additions made by Dr. Hutchinson are appropriate 
and useful, and so well done that we wi?h there were 
more of them.— Am. Practitioner, Feb. 1877. 



Island, JV. P- 



JJ A MILT OS {ALLAN Mr LANE), 31. D., 

Attending Physician at the Eobpital for Epileptic* and Paralytica, BlackicelV 
and ut iL<- Oat- 'aJients' Department of the Neu\York Hospital. 

NERVOUS DISEASES THEIR DESCRIPTION AND TREATMENT. 

In one handsome octavo volume of about BOO pages, with forty eight illustrations. {Shortly.) 
i i, • objeol of the author has been to fu.nish to the student and practitioner in a clear and 
conci-e form guide to the diagnosis and treatment of affections of the nervous system, em- 
bodying the very great advances made during the lust few years in our knowledge of these dis 
Unusual opportunities in public and private practice have qualified him tor this work. 
and his deeire has been to render it Btrictly prnctioal, adapting it to the wants not only ol the spe- 
bal oftb< neral practitioner. Partioular eare has therefore been devoted to the manage- 
ment ofnei roUS diseases, and in an appendix will he found n careful selection ol well-tried formula. 

CJARTSHORNE (HENRY), M.D., 

1 1 Professor of Bygisnt in the University of Pennsylvania. 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MED1- 

CiNK. A handy-hook for Students and Practitioners. Fourth edition, revised and im- 
proved. With about one hundred illustrations. In one handsome royal 12mo volume, 
ol nboul 550 pages, e loth, $2 68; half hound, $2 88. {Lair/,/ bsmd.) 
■\ be i borough manner In which the author has labored to fully represent in this favorite band- 
book the most advanced eondition of practical medioine is shown by the faol thai the present 
iini more than 260 additions representing the investigations of 172 authors nol re- 
: * in previous edition.-. Notwithstanding an enlargement of the page, the sise has been 
-i\i\ pages. A Dumber of illustrations have been Introduced which it is hoped 
will facilitate tbe comprehension of details^ the reader, and no effort has been spared to make 

dine worthy a emit iniiancr of the very great favor with which it has hitherto Keen reeen ed. 

s advances In medicine, Is admirably condemn 

«i mi im , we yet sufficiently expHeil for all tbe purpoeeets 

Va Med Monthly, thus making it by far the bent work of its obs raster 

bal c pre! sd- ever pnbll,bed.-0»»d tiOlinio,Oei 34, 1874. 

,,.„, ki ,. m proved apon.- Chicago Med Without doubt tbe best book of the Mod published 

/• ,./,„,„</ Efov i '" llM ' Bualteb laoguaga,— At. Louis Med. and Surg. 

i iy ap with nil the recent • / "">" . - v,v - ls71 - 



Henry C.Lea's Publications — {Practice of Medicine). 



IT 



TpOTHERGILL {J. MILNER),M.D. Edin., M.R.C.P. Lond., 

■*- Asst. Phys to the Went Lond H<<s(>. : Axst. Phys. to the City of Lond. Ho*p.,etc. 

THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the 

Principles of Therapeutics. In one very neat octavo volume of about 500 pages : cloth, 

$4 00. {Now Ready.) 
It may be sail that the scope of this work is not dissimilar to th;it of the well known 
" Principles of Medicine," by Dr J. C. B. Williams, now long out of print, which in its day 
met with such unusual acceptance. More practical in its character, however, it seeks to bring 
to the aid and elucidation of positive therapeutics, the vast accumulation of scientific fac 
theories made by the present generation, pointing out the measures to be adopted at the bedside 
and establishing them on firm rational grounds. Such a work, by a first-! ate man, and fully 
up to the advanced condition of science, cannot fail to prove of the utmost -ervic-e to both 
student and practitioner. 



Our friends will find this a very readable book : and 
that it Rheds light upon every theme it touches, causing 

the practitioi er to feel more Of r lain of bis diagnosis in 
difficult cases. We confidently commend the work to 
our readers as one worthy of careful perusal. Jt lighis 
the way over obscure and difficult passes in medical 
practice. The chapter on the circnli tun of the blood 
is the most exhaustive And instructive to be found. It 
is a hook every practitioner reeds, and would have, if 
he knew how su jr stive and helpful it would be to 
him. — St. Louis Mn/. and Surg. Jour >., Ayrii, 1<S77. 

The object is one of the most important winen a med- 
inal writer can propose to himself, tor therapeutics is the 
iroal of medicine, and the plan is an excellent one. In 
justice to Dr. Fothergill we ought to say that lie has ad- 
hered to his plan thromrbout the work with fidelity, and 
has accomplished bis object with a rare degree of success. 
We heartily commend his book to the medical student 
as an honest and intelligent guide through the mazes of 
therapeutics, and assure the practitioner who has grown 
gray in the harness that he will derive pleasure and in- 
struction from its perusal The imperfections and 
errors which we have noticed are few and unimportant. 
On the other hand, the excellences are many and patent. 
Valuable suggestions and material for thought abound 
throughout. The chapters on body heat and fever, in- 
flammation, action and inaction, and the urinary sys- 
tem are particularly good. The descriptions of patho- 
logical conditions, and the character of the therapeutic 
measures advised give evidence of sound clinical obser- 
vation.- Boston Med. and Surg Journal, Mar S. 1^77. 

The strong good sense, the racy style, the practical 
cnaracter of his instruction, are qualities in the author 
which commend him to American physicians. In the 



volume before us Dr. Fothergill appears in hi* best 
mood. Our readers, especially the 3 ounger mei 
1 he profession will find thie a mi - I 
ful look. There are few old practitioners who will not 
be benefited by its perusal. We commend it to all 
cla«ses of readers, with theexpression of belief 1 hat those 
who buy it will be hardly content to close it until the 
last leaf is turned over.— (Jin im aft C inic, .Mar 3, 1S77. 
It is our honest conviction, alter a careful perusal of 
this goodly octavo, that it represent* a great amount "f 
etirnest thought ami painstaking work, and is tin 
one of those books which both deserve and are likely to 
survive. This book, although written ostensibly tor the 

young and inexperienced, may he vry profitably studied 
by those who bave been practising their \ ■: 
more or less empirically for thirty or forty years. We 
particularly recommend the chapters on Public and 
Private Hygiene, food in Health and Ill-Health, and 
the Conclusion — the Medical Man at the Bedside. The 
last is high-toned, and indicate- much shrewdness o I ob- 
servation. Our space will not admit of further quotation. 
We content ourselves with again recommending the 
book very cordially. — Edin. Med. Jonrn., Jan. 1-77. 

It is of great advantage to the practitioner to have gen- 
eral principles to guide him. and that he should not, 
when confionted with an assemblage of pathological 
symptoms, be at the mercy of an unreasoned experience 
of a similar ease, or be obliged to swear in verba >■ 
lie will rind reasons in this work for not looking upon 
drugs as grouped in fixed and unalterable categories, 
but learn when and why be may give opium to cause 
purgation, and castor oil to check it. We strongly re- 
ccmujend it to our readers. — 'The. London Praculiontr, 
Jan. 1577. 



T INCOLN [D. F.), M.D., 

•*-* Physician to the Department of Nervous Diseases, Boston Dispensary. 

ELECTRO-THERAPEUTICS ; .1 Concise Manual of Medical Electri- 

city. In one very neat royal 12mo. volume, cloth, with illustrations, $1 50. (Just Issued.) 

This little book is considering its size, one of the I thereby supplying a real want, instead of helpicg 
very best treatisesin the language od the subject thai merely to flood the literary market. Dr. Lincoln s 
ha" come to our notice, possessing, among others, the | style is usually remarkably clear, and the whole 
rare merit of dealing avowedly and actually with | book is readable and interesting. — Boston Med. and 
principles, mainly, ratherthau with practical details, | Surg. Jovrn., July 23, 1S74. 



R 



OBERTS ( WILLIAM), M. D.. 

Lecturer on Medicine in the Manchester School of Medicine. Ac. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
ond American, from the Second Revised and Enlarged London Edition. Id one ' 
and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. ( /. 
Published.) 

and a host of other well-known writers upon this sub- 
ject. The characters of urine. ; and pa- 
thological, as Indicated to the nak 
micr08COpica] and chemical i n \ re cod- 

ciseiy represented both by description and 

executed engravings. — Cinciu mi. Uoi 



The mostcompleteand practical treatise upon renal 
disease- we have examined It is peculiarly adapted 
to the wants of the majority of American practition- 
ers from its clearness a nd simple announcement of t In 
facts in relation to diagnosis and treatment of uriuar) 
disorders, a nd contains in condensed form the in vest i 
gallons of Beuce Jones, Bird, Beale, Hassall, Prout. 



LECTURES ON TI1K STUDY OF FEVER. By A. 
HUDSON, M.D., M.R.I.A., Physician to the Meath 
Hospital In one vol 8V0. t cloth, $2 fiO. 

A TREATISE ON FEVER. By Robrbt D Lyons, 
K C C. Iu one ocavo volume of 382 1 pages, cloth, 
>•_• 25, 

CLINICAL OBSERVATIONS ON FUNCTIONAL 



NERVOUS DISORDERS BvC M urnriE] 

H i> , Physician to 81 M 8ec 

end American Edition. ID O « >ct« v,. 

volume of 348 pagea, olol I . I 

BA8B ^M OH REN \i DIG 
to their Dtagooali and Treatment, With 

tions. Iu one I2m0. Vol 



18 Henry C. Lea's Publications— (7) incases of the Chesf, &c). 



J?LINT {AUSTIN), M.D., 






Professor of the Principles and Practice of Medicine in Sellevue Hospital Med. College, N. T. 



PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY. SYMPTOM- 
ATIC EVENTS AND COM PLICATIONS. FATALITY AND PROGNOSIS, TREAT- 
MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin 
Flint. M D . Prof, of the Principles and Practice of Medicine in Bellevue Hi spital Med. 
College, New York. In one handsome octavo volume: $3 50. {Lately Issued.) 
This volume, containing the results of the author's extended observation and experience oil a 
subject of prime importance, cannot but have a claim upon the attention of every practitioner. 
Tliiv book oontaiaF an analysis, in the author's lucid titioner. While the author take* i>svt" with many of the 



• the not, s which he b is made in eeveral hun- 
dred cases in hospital and private practice. We com 
mend the hook to the perusal of all interested in the 
study of tins disease. — Boston Med. and Sara journal, 
L876. 
The name of the author is a sufficient guarantee that 
is of practical value to loth student and prac- 



leading mind:- of the day on important questioas arising 
m the study of phthisis, the strong testimony of expo 
rience and authority will have great weight with the 
seeker after truth As the result of clinical study, the 
work is unequalled.. 1 — St. Louis Med. and Surg Journal, 
March, 1S7G. 



gY THE SAME AUTHOR. (Now Rea,u n 

A MANUAL OF PERCUSSION AND AUSCULTATION; of the 

Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In 
one handsome royal 12mo. volume: cloth, $1 75. 
In this little work the object of the author has been to present in a clear and compact form 
eting condition of physical exploration, showing the manner of conducting it and the 
diagnostic value of the several signs thereby elicited. 

w i d confidently recommend this treatise to all I rightly value fhe*e modes of exploration of disease. 
who would learn auscultaii >n and percussion, and | —BrtHsh and For. Med.-Chir Rto., July, 1877. 



1) r THE SA ME Al'THOR. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 

edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 

Dr. Flint chose a difficult subject for his researches tnd clearest practical treatise on those subjects, and 

and has shown remarkable powers of observation should be in the hands of all practitioners aud stu- 

and reflection great industry, In his treat- leats. It is a credit to American medical literature. 

ment of it. His book mnsi be considered the fullest I -Amer.'Journ. of the Med Sciences, July, 1860. 



7>r THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 
Dr Flint's treatise is one of the most trustworthy) mcy to over-refinement aud unnecessary mluuteness 
galdes which we can consult. The style is clear and vhi'ch characterizes many works on the. same snb- 
dlstinct, and is also concise, heingfree from that ten d-j set.-*- Dublin Medical Press, Feb. 6, 1867. 



w 



ILLIAMS (C. J. B.). M.D., 

igniting Phyeiolam to the Hospital for Consumption, Brompton. 
PULMONARY CONSUMPTION; Its Nature. Varieties, and Treat- 

With an Analysis of One Thousand Cnses to exemplify its duration. In one neat 

o volume of about 350 pages, cloth, $2 50. (Lately Published.) 



1BAMBER8 (T. K). M.D.. 

/ ilting Physician to St Mary's Hospital, London. An, 

A MANUAL OF DIET AND LIEGIMEN IX HEALTH AND SICK- 

NESS. In one handsome ootavo volume. Cloth, $2 75. (.last issued.) 



jm PHI H re and Treal -lent, win, an 

aceonn t of the n letory a rari- 

D i a 'mI 

i Jm ... volume, 
cl..th - 

OF THE HEART AN I 

,S. Third American edition. I u 
I 
I n.1,1 .1 in i. LUNGS \M* \ I R> 

I . ond a ".I 

i n one hanriiioini 
volnm 

'MA. 1 vol. Bto., cloth. 

WITH PI EARLY AND BE 

I. *'-* 2f. 



LECTURES OH THE DISEASES "F THE STOMACH. 
With an Introduction on Its \ natomy and Physio- 
logy. By William Bbinton. M l> . F R 8 From 
tbe aeoond and enlarged London edition. Wit h II- 
insi r.itions .. n wo,., i in one hand Home octavo 
rolanre of abonl 800 page* i cloth, |i 

in kMBBRS'S RESTOH ITIVE MEDICIN B. An Bar- 
relan aunoal Oration. With Two Sequela Id 
one very handsome vol. sm;iii l2mo , eloih, *i 00. 

PAVY'f? TREAT, 8E ON THE FUNCTION OF DI- 
GESTION; Ita DUordera an.) their Treatment. 

E i ■■ be aeoond Loudon edll Ion. i n i be od- 

aome roln , Rtnall oota ro, oloth, - 

PAVY'8 TREATISE ON POOD AND DIETETICS 
Physiologically and rherapentloally CoiiMtdered. 
in one band te ootavo volume ol nearly BOO 



Henry C. Lea's Publications — ( Venereal Diseases, (he). 



19 



RUHSTEAD (FREEMAN J.), M.D., 

■*-* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York. Ac. 

THE PATHOLOGY AXD TREATMENT OF VENEREAL DIS- 
EASES. Including the results of recent investigations upon the subject. Third edition, 
revised and enlarged, with illustrations. In one large and handsome octavo volume of 
over 700 pages, cloth, $5 00 ; leather, $6 00. 
In preparing this standard work again for the press, the author has subjected it to a very 
thorough revision. Many portions have been rewritten, and much new matter added, in order to 
bring it completely on a level with the most advanced condition of syphilograpby, but by careful 
compression of the text of previous editions, the work has been increased by only Bixty-foui 
The labor thus bestowed upon it. it is hoped, will insure for it a continuance of its position as a 
complete and trustworthy guide for the practitioner. 

A valuable work ou Venereal Disease-, which not /enereal diseases, that if may seem almost -upernu- 
only has a wide circulation in (his country, and ms to 6ay more ofit than that a new edition has been 
been accepted as the staudard, but appears to have issued. But the author's industrv has rendered this 



formed the basis, to a large exteut, of many of the 
Looks and articles which have been written on the 
same subject and published in England.- The Glas- 
gow Med. Journ,.. Oct. 1877. 

It is the most complete book with which we are ac- 
quainted in the language. The latest views of the 
best authorities are put forward, and the information 
is well arranged — a great point for the student, and 
still more for the practitioner. The subjects of vis- 
ceral syphilis, syphilitic affections of the eyes, and 
thetreatment of syphilis by repeatedinoculatious are 
very fully discussed. — London Lancet, Jan. 7, IS71. 

Dr. Burastead's work is already so universally 
known as the best treatise in the English language on 



jew edition virtually a new w. re, and so merits as 
much special commendation as if n - predecessors had 
not been published. As a thoroughly practical bo.'k 
on a class of diseases which form a larze share of 
nearly every physician's practice, the volume before 
u- is i.v far the beat of which we have knowledge.— 
.V. F. Medical Gazette, Jan. 28, 1S71. 

It is rare in the history of medicine to find 
book which contains all" that a practitioner n 
know; while the possessor of " Bnmstead on Vene- 
real" has no occasion to look outside of Its covers for 
anything practical connected with the diagnosis, his- 
tory, or treatment of these affections.— N. Y Medit '■ I 
Journal, March, 1871. 



(1ULLERIER (A.), and 

^ Surgeon to the Hdpital du Midi. 



J?UMSTEAD (FREEMAN J.). 

-*~* Professor of Ventre" I Diseases in the. College of 
Physicians and Burgeons. X. Y. 

AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bums.tead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth. $17 00 ; also, in five parts, stout wrappers, at $3 per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. 
A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
We wish for once that our province was not restrict- 
ad to methods of treatment, that we might say some- 
thing of the exquisite colored plates in this volume. 



— London Practitioner, May, 1S69 

As a whole, it teaches all that can be taught by 
means of plates and print. — London Lancet, March 
18, 1869. 

Superior to anything of the kind ever before issued 
on this continent. — Canada Med. Journal, March, '69. 

The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published.— 
Dominion Wed. Journal, May, 1S69. 

This is a work of master hands on both sides. M 
Cnllerier is scarcely second to, we think we may truly 
say is a peer of the illustrious and venerable Ricord, 
while in this country we do not hesitate to say that 
Dr. Bnmstead, as an authority, is wirhout a rival 
Assuring our readers that rhe-e illustration?" tell the 
whole history of venereal disease, from its inception 



'o its end. we do not know a -ingle medical work, 
svhich for its kind is more necessary for them to have. 
—California Med. Chxzette, March. 1869. 

The most splendidly illustrated work in the Ian- 
?ua?e, and in our opinion far more useful than the 
Prenoh original —Am. Journ. Med Sciences, Jan. 6 C . 
The fifth and concluding number of this magnificent 
work has reached us. aud w^ hare no hesitation iD 
saying that its illnstratinns surpass those of previous 
numbers. — Bo.st Med and Surg. J 7 ., Jan. 141 
Other writers besides M. Cnllerier nave«iven us a 
, good account of the diseases i>f which he treais. but 
1 no one has furnished us with such a complete - 
of illustrations of the venereal diseases. There i*. 
however, an additional interest aud value pose 
\ by the volume before us ; for it is an American reprint 
and translation of M. Cnllerier's work, with inci- 
dental remarks by one of the most emiueut Am 
syphilographers, Mr Bnmstead. — Brit, and 
MeA4e.n-nh.if, Review, July, 1S69. 



t EE (HENRV). 

Prof of Surgery at the R tyal College of Surgeons of England, tie. 

LECTURES OXSVPHILIS AND ON SOME FORMS OF LOCAL 

DISEASE AFFECTING PRINCIPALLY THE ORtl \\> OF GENERATION. In one 

handsome octavo volume: cloth; $2 25. {Lately Published.) 

modifications nf these processes In patient* 

syphilitic; primary and secondary Byphilitic 

the mucous membranes and thtdr liability to comma- 

nieate constitutional -\ | hilis, ■ ■ Ti i 

clinical material lllastrntln? these to| 

quoted.- A ■ 



The work is valuable, as it treats unite fully of sub 
jects which arc not dwelt npon In the systematic works 
of other English authors of the present day. as the looe 
alaMlity of syphilitic blood i theconditions under which 
the secretion- of primary and secondary syphilitic man- 
ifestations maybe inoculated naturally or Artificially; 
the morbid processes produced by such Inoculation; the 



II 1 



LL (BERKELEY), 

Surgeon h, the Look BosytUU, London. 

ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In 

one handsome octitvo volume ; cloth, $3 25. 



20 



Henry C. Lea's Publications — (Diseases of the Ski: , the.) 



J? )X [TILBURY), M.D., F.R.C.R, and T. C. FOX. 13. A., M R.C.S., 

-*- Physician to the Department for Skin Diseases, I'virasitv Colli gt- Uosjilol 

EPITOME OF SKIN DISEASES. WITH FORMULA. For Stu- 

dknts and Practitioners. In one handsome 12uio. volume, of 120 pages: cloth, $1. 
(Just Issued.) 

clear and corn-No description is trivon of the treatment of skin diseases are accurately and completely 

e'enichtary leeiona ard ihe author's remarks o U the stated without being cramped. The book is so well ar- 

tur, complications, and modifications of ranged that the reader will have no difficulty in finding 

eruption^, toother with th»ir practical hints on the ex- at once exactly tlie information lie may require A 

animation of <kin di~ ases, will le of erreat Assistance 

to the n-'vi -e in this department of medicine. We know 

of no other which, in so little space contains so much 

a — N. V. MeA. Jnurn., Dec. 1S76. 

It baa do especial features other than it is ooiicis* and 

cpiite practical. The early diapers, treating (f ele- 

| matters, in the study of s'-.in dNeises. are very 

ist of formulae is excellent.— Archives of 

Clinical Surge y, Dec 1876. 

r< neglect the study of diseases of the skin, it 

will not be for lack of opportunities of instruction. This 

little handbook contains wonderfully condensed know- 

' cannot io>t be most useful to everv one who 

will read it.— Anerican Pract&f'ont , Jan 1877. 



carefully compiled formulary of remedies for skin affec- 
tions and some notes on diet in skin diseases, considera- 
bly enhance the value of the epitome. — London Lancet. 
Nov. 4. 1876. 

It must be admitted that even those well prepared for 
general practice find diseases of the skin difficult of clas- 
siflcati >n. and as difficult of diagnosis, and that nothing 
is more desirable than some work which, not elaborate 
' in nature, shall be a useful ordinary guide, and issued 
bv some one of recognized authority. It is believed that 
] this manual of Tilbury Fox and T.C. Fox exactly meets 
the wants indicated 1 1 epitomizes, in a very short com- 
pass, the clinical feature-- in the treatment of diseases 
of the skin. The volume N so small that it can be car- 
ried in the pocket, while the text furnishes briefly, but 
Ibis little work oannoi fail toaeqmrea largenrceof clearly, the information desired bv the general praoti- 
ln a verv small compass all the essential tinner, ft meets full v an almost universal want.- Am. 
points oi the classification, diagnosis, symptoms, and g;. Weekly Jan 6 1877 



w. 



II jSON (ERASMUS). F.R.S. 

OX DISEASES OF THE SKIN. With Illustrations on wood. Sev- 
enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over 800 pages, $5. 

A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- 
EASES OF THE SKIN;" consisting of twenty beautifully exeouted plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
and embracing accurate representations of about one hundred varieties of disease, most of 
them the size of nature. Price, in extra cloth, $5 50. 
Also, the Text and Plates, bound in one handsome volume. Cloth, $10. 
Jj V THE SAME AUTHOR. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 
eases op the skin. In one very handsome royal l2mo. volume. $3 50. 

fifELIGAN {J.MOORE), M.D..M.R.I.A. 

ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 

volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of 
disease. Cloth, $5 50. 

to which the particular case may belong. While 
ooking over the "Atlas" we have been iuduced lo 
xamine also the "Practical Treatise.' - and we are 
inclined to consider it a very superior work, con - 
biniug accurate verbal description with sound vlewk 
of the pathology and treatment of eruptive diseases. 
— Glasgow Med. Journal. 



vith exquisitely colored plates, Ac 
Cloth, $5 50. 
The diagnosis of eruptive disease, however, under 
'•••-, le very difficult. Nevertheless, 
ftinly, "as far as possible," given 
■ i and accurate representation of this class of 
I 8, and t here can he no doubt" that tin 

will he of great use to the student and practitioner in 
drawing a di;:. | he class, order, and species 



H 



ILL1ER [THOMAS), M.D., 

Physician to the Shin Department of University College Hospital, Affi 
HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 
Second Am Ed. In one royal 12mo. vol. of 358 pp. With Illustration Cloth. $2 25. 



n oonscienth a«ly recommend it to the Btu- 
deal : i be stj . ml to read, the 

■ icrlptiona Of disease, with 

commend* d, are frequently 
llustrated with well-recorded cases.— London Med. 

Ton. 



It \h a concise, plain, practical t realise on the vai 1- 
one dl eases of the skin ; |u*1 bucIi b work, indeed, 
as was much needed, both by medical Students and 
practitioners. — Chicago Medical Examiner, May, 



^MJTH (EUSTACE), M. P.. 

Physii tan t>> tht Northwest London PVei Dispt nsary for 8i( k Children, 

A PRACTICAL TKEATISE ON THE WASTING DISEASES OF 
\<'Y and OHILDHOOD. Second American, from the second revised and enlarged 
BngU b edition. In one handsome dotavo volnmcr, doth, %% :>(). {Lately Issued.) 

icrlbed a.a i practical handbook of the common dis- 

■ ■ in Idio i), mi mi in e rou s h re the sffeotionfl con- 

either collaterally or directly. We are 
.m-'i'i.i i iite, i wiih no Bafer golds to the treatment of 
children's diseases, and few works give the insight 
into the physiological and othei peculiarities ofohi]< 

Smith's hook does — Brit, Mid Journ., 



d oa treble book. The 

• '.'.ill -cue.. 

many - nbjecti 
W i a| le to sou tan I •• n el 

0l I Id hOOd, thai H lie;, 

of children tnnsi n< 
i.r l| on oi tna d j sffeotlona dren I bel i> 

srell \pril s, is7l 
doas by Dr . ,,i fairly be 



Henry C. Lea's Publications — (Diseases of Children). 21, 



SMITH (J. LE WIS), M. D., 

*J Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N T. 

A COMPLETE PRACTICAL TREATISE OX THE DISEASES OF 

CHILDREN. Third Edition, revised and enlarged. In one handsome octave volume 
of 726 pages. Cloth, $5 ; leather, $6. (Just Issued.) 

The eminent success which this work has achieved has encouraged the author, in preparing 
this third edition, to render it even more worthy than heretofore of the favor of the profi 
It has been thoroughly revised, and very considerable additions have been made throughout. 
To accommodate these the volume has been printed in a smaller type, 80 a- to prevent, any 
notable increase in its size, and it is presented in the hope that it may attain the position of 
the American text book on this important department of medical science. 

This work took a stand as an authority from its first I edition will confirm and add to its reputation. Having 
appearance, and everyone interested in studying tin: been brought op to the presenl mark in the rapid ad- 
diseaaes of which it treats is desirous of knowing what vanoe of medical science, it U the basl work in oar 
improvements are apparent in the successive editions, language, on it- range of topics, for the An erican prac- 
The principal additions to which we refer, and which titioner. — Pacific Mai. an&Surg. Jaurn., Pen 
will be the distinguishing features of the third edition, ] Dr . Smith's Diseases of Children la certainly the moat 
are chapters on diphtheria, cerebrospinal meningitis, v ., lim i,| ( . W( , r u on the subjects treated thai the praeti- 
and rotheln. The former disease is considered much liun ,, r ,.. 1U provide himself with. It is fully abreast 
more in detail than formerly, and a great amount of wi , h ( , v advance: it phould be in the bands of prao- 
very practical information is added, and altogether it is titi( , m>r< generally, while, because of the con 
one of the most comprehensive and one of the best writ- ai|(1 c ] earnepfl f ptyle of the writing nf the author, every 
ten chapters of the subject we have thus far read. His profesTOr of diseases of children, if he has not R ready 
description ol cerebrc-spinal meningitis, founded also jone so, ahouid adopt tWsae his text-book —Fo.ifedtcai 
for the most part on personal experience, is admirably Monthly Feb l s To 

clear and exhaustive. — The Med. Record. Feb. 19, 1876. j mi ' ,,..',.,. ,, , V1 . w ; „ „ 

' I The thir<l edition of this really valuable work is now 

In presenting this deservedly popular treatise; for the oe fb re us, with a hundred pages of additional matter, 
third time to the profession, Dr. Smith has given it a an al , ( . n .,i aizeofpage, new illustrations, and new type. 
careful preparation, which will make it of decided ru- of thediseases treated of for the first time, we notice 
pariority to either of the former editions. The position r6theln :md cerebrospinal fever, which lately prevailed 
of the author, as physician and consultant to several h) epitl emic form in some parts of the country. The 
large children's hospitals in New York City, has fur- , article U(l0n diphtheria, containing the latest develop- 
nixhed him with constant occasions to put his treatment , ni . nts [ n the patliology and treatment of that dread <lis- 
to the test, and his work has at once that, practical and (j;(se> wn ;,. n sn lately ravaged our country, is peculiarly 
thoughtful tone which is a marked characteristic of the juteresting to every practitioner. We gladlj welcome 
best productions of the American medical press.— Mai. this ft tandar I work. and rheerfollj recommend it to our 
and Surg. Reporter, Feb. 187& readers as the best on this subject in the Knglisb lai - 

The former editions of this hook hare '.riven it the ' »\i;vie— Nashville Journal nf Med. and Surgery, March, 
highest rank among works of its class, and the present I lbTu. 



c 



ONDIE (D. FRANCIS), 31. D. 

A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 

Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
printed pages, cloth, $5 25 ; leather, $6 25. 

The present edition, which is the sixth, is fully up I teachers. As a whole, however, the work is the best 
to the timesin the discussion of all those pointsin the | American one that we have, and in it- special adapta- 
pathology and treatment of infantile diseases which I tion to American practitioners it certainly has no 
have been brought forward by the Germau and French | ■jqual. — New York Mud. Record, March 2 ; 



\XTEST (CHARLES), M. D., 

* * Physician to the Hospital for Sick Children, *<?. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 

HOOD. Fifth American from the sixth'revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. (Lattftf Tssut 

The continued demand for this work on both sides of the Atlantic, and its translation inl 
man, Fren -h, Italian, Danish, Dutch, and Russian, show that it tills satisfactorily B want exten- 
sively felt by the profession. There is probably no man living who can speak with the authority 
derived from a more extended experience than Dr. West, and his work now presents the results of 
nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 
cases which have passed under his care. In the preparation of the present edition he ha- omitted 
much that appeared of minor importance, in order to find room for the introduction of addition:!! 
matter, and the volume, while thoroughly revised, is therefore not increased materially in size. 

Of all the. English writers on the diseases of chil- I living authorities in the difficult department 
dren, there is no one so entirely satisfactory to us as | oal BOieuce in which he is most widely kuown.— 
Dr. West. For years we have held his opinion as I Boston Med, and Surg. Journal. 
j adicial, and have regarded him as one of the highest | 



DT THE SAME AUTHOR. {Lately Issued.) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD 

HOOD; being the Lumleian Lectures delivered at the Royal College ofPbysi 
don, in March, 1871. In one volume, small L2mo., cl »th, $1 00. 



OQ 



Henry C. Lea's Publications — (Diseases of Women). 



rrHOMAS {T.GAILLARD),M.D. t 

Professor of Obstetrics, &•(■.. in the College of Physicians and Surgeons, N. T., Ac. 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 

edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 

BOO pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. {Just Issued.) 

The author has taken advantage of the opportunity afforded by the call for another edition of 

this work to render it worthy a continuance of the very remarkable favor with which it has been 

received. Every portion has been subjected to a conscientious revision, and no labor has been 

spared to make it a complete treatise on the most advanced condition of its important subject. 

sioa wo nl J remark that, as a teacher of gynaecology, 
both didacticand clinical, Prof. Thomas ti a- certain y 
taken the lead far ahead of his confreres, and as an 
author he certainly has met with uriueual and mer- 
ited success.— Am Joutn. of Obstetrics, Nov. 1874. 
This volume of Prof. Thomas in its revised form 
is classical without being pedantic, full in i he details 
of anatomy and pathology, without ponderous 
translation of pages of Germnn literature, describes 
distinctly the details and difficulties of each opera- 
tion, without wearying and useless minutiae, and is 
in all respects a work worthy of confidence, justify- 
ing the high regard in which its distinguished au- 
thor Ls held by the profession; — Am. Supplement, 
Obstet, Jorirn. Oct. 1S74. 

Professor Thomas fairly took the Profession of the 
Uuited States by storm when his book first made i's 
appearance early in lStiS. Its reception was simply 
enthusiastic, notwithstanding a few adverse criti- 
cism-! from our transatlantic brethren, the first large 
edition was rapidly exhausted, and in six months a 
second one was issued, aud iu two years a third one 
was announced aud published, and we are now pro- 
mised the fourth. The popularity of this work was 
not ephemeral, and its success was unprecedented in 

i the annals of American medical literature. Six years 
is a loug period in medical scientific research, but 

j Thomas's work on " Diseases of Women" is still the 
leading native production of the United States. Tbe 
order, the matter, the absence of theoretical dispute- 
tiveness, the fairness of statemeut, aud the elegance 
of diction, preserved throughout the entire range of 

i the book, indicate that Professor Thomas did not 

i overestimate his powers when he conceived the idea 
and executed the work of producing a new treatise 
upon diseases of women. — Prof. Pai.i.kn, in Louis- 
ville Med. Journal, Sept. 1^71. 



A w rk which has reached a fourth edition, and 

that, too, in the short -pare of five years, has achieved 
a reputation which places ir almost beyond the reach 
of criticism, and the favorable opinions which we have 
already expressed of the former editions seem to re- 
quire that we should do little more than announce 
this new Issue. We cannot refrain from saying that, 
as a practical work, tbis is second to none in the Knjj- 
liflh, or. indeed, in any other language. The arrange- 
ment of tbe contents, the admirably clear manner in 
which the subject of the differential diagnosis of 
several of the di eases is handled, leave nothing to be 
desired by the practitioner who wants a thoroughly 



clinical work, one to which he can refer in difficult 
loubtful diagnosis with the certainty of train- 
ing light and instruction. Dr. Thomas is a man with a 
very clear head and decided views, and there Seems to 
be nothing which he bo much dislikes as hazy notions 
of diagnosis and blind routiueand unreasonable thera- 
Phe student who will thoroughly study this 
book and test its principles by clinical observation, will 
certainly not be guilty of these faults.— London Lancet, 
Feb. [3, Is;.',. 

The latest edition of this well-known text-book 
retains the essential characters which rendered the 
earliest so deservedly popular It is still pre-emi- 
nently a practical manual, intended to couvey to 
students in a clear and forcible manner a sufficiently 
complete outline of gynaecology. In a word, we 
should saj that any one who intended to make a 
special study of gyna?cology could hardly do better 
than to begin with a minute perusal of this book, and 
that any one who intended to keep gvusecology sub- 
ordinate to geaeral practice, should hardly fail to 
have it on In. nil for future reference. — N. Y. Med. 
Jov /•/(.. Jan. 1S7.3. 

Reluctantly we are obliged to close this unsatis- 
factory notice of so excellent a work, and in conclu- 



B 



ARNES [ROBERT), M. D., F.R. C.P., 

Obstetric Physician to St. Thomas's Hospital, A-e. ♦ 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 

C II DISK ASKS OF WOMEN. Second American, from the Second Enlarged and Revised 
English Edition. In one handsome octavo volume, w.th many illustrations. {Preparing,.) 

CtWA FNE [JOSEPH GRIFFITHS), M.D., 

*~J Physician- Accoucheur to the British General EJospitat, &c 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 

.MK.\CIX<; MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
London Edition, with Additions by E. R. Hutchins, M. D. With Illustrations. In one 
neat l2mo volume. Cloth. $1 25. {Lately Issued.) 
*«* So,- p. 1 of this Catalogue lor the terms on whi<-h this work is offered as a premium to 
■Ufa crib- is to the " Amkiihan Jot i:s \ i, ok thk MEDICAL SCIENCBS." 



w 



1NCKEL (F.). 

Professor ana Director of the Gynaecological Clinic in the university of Rostodk. 

A COMPLETE TREATISEON TIIK PATHOLOGY AND TREAT- 
MENT <>f CHILDBED, for students and Practitioners. Translated, with the consent of 
tip- author, from the Beoond German Edition, by Jamks Read Ciiadwick, M D. In one 
nau.ro volume. Cloth, $4 <M). {Lately U$ue&.) 



\v 

will 



feel quite lure thai tin- profoj l< n "t fhl country 
i . .- i hit Intei e ic in-. i work a oortUal 



Cmt ■ut, .iu Med. .v. w», J une, i s 7'.. 
many thU treat! ■ i- regarded ■ • a itandard 

authority in tii« branch "i i Heine, and ai li eon- 

in tin- patnologj Mini treat* 

In t" tin- puerperal condition, 

,, ol the profea- 



* rin- vwo-k whs written, aa the author tells an in bis 
preface, i" lupply :i Irani arlainu from tin- very brief 
lonslderattoti given to puerperal diaeaaea b\ writer a on 
Obatetrloa, In whlofa reaped it aeema tin 1 profeaaion in 
iiis country la nut different from oura, and to fill a blank 
lefl between the treatlaea upon tie subject already in 
ti,.- ti.i-i. and tbe present atandpoinl orartenoe. Tbe 
irork baa reached a aeoond edition, and bear* evidence 

thr boot ..I careful atndy and praetioal experience, 

La ita title impliea.lt |a a manual rather than » ti 
ii mi Journal oj Htd. Sou n> < -. \ prll, I —7 1 . 






Henry C. Lea's PuBLicATiON8—(Z>isease* of Women). 



23 



H 



ODOE {HUGH L.), 31. D., 

Emeritus Professor of Obstetrics, &c, in the. University of PennsxjUnr. to. 

ON DISEASES PECULIAR TO WOMEN; including Displacements 

of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 

From Prof. W H Btford, of the Rush Medical Professor Hodge's work la truly an original one 

College, Chicago. m beginning to end. consequently no one 

...... ., , ,^,^ a „A an A -use its pages without learning >oriiething u»'vr 

The book bears the impresg of a master hand and * n fab£lt* to the study of women's d 

«aet ( " l *F**™ wo ;>J™Zl™™*^ great ralne, and is abaJdantly able to stand on its 

raeaion. In diseases of women Dr^ Hodge has estaj- J mer it 8 ._^. y. Medical Record, Sept. 15, 1868. 

lished a school of treatment that has become world- ' 

wide in fame. 



TKTEST {CHARLES), M.D. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
$3 75 ; leather, $4 75. 
As a writer. Dr. West stands, in our opinion, Be- seeking truth, and one that 
eond only to Watson, the "Macaulay of Medicine 



he possesses that happy faculty of clothing instruc- 
tion in easy garments ; combining pleasure with 
profit, he leads his pupils, in spite of the ancient pro 
verb, along a royal road to learning. His work is one 
which will not satisfy the extreme on either side, but 
ii is one that will please the great majority who are 



11 convince the studen 
that he has committed himself to a candid, »afe, aBd 
valuable guide. —N. A. M«.d.-Chi-ntrg. Bev&MB. 



We have to say of it, briefly and decidedly, that li 
is the best work on the subject in any language, and 
that it stamps Dr. West as the faciU princeps of 
British obstetric authors.— Edinburgh Med. Journal. 



DHWEES'S TREATISE ON THE DISEASES OF FE- [ ASHWELL'S PRACTICAL TREATISE ON THE DIS- 

MALES. With illustrations. Eleventh Editioc EASES PECULIAR TO WOMEN. Third American, 

with the Author's last improvements and correc from the Third and revised London edition. 1vol. 

tions. In one octavo volume of 536 pages, wit* 8vo.. pp. ">2S. cloth iS 50 

places, cloth. Wnn MEIGS ON THE NATURE. SIGNS, AND TREAT- 

CHURUHILL ON THE PUERPERAL FETER AND MENT OF CHILDBED FEVER. 1 vol. 8vo. pp. 

OTHER DISEASES PECULIAR TO WOMEN 1vol. ^65, cloth. $2 00. 
8vo., pp. 450, cloth. $2 50. 



WANNER {THOMAS H.). M. D. 
ON THE SIGNS AND DISEASES OF PREGNANCY. First Amerieci 

from the Second and Enlarged English Edition. With four colored plates andillustrationf 
on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
With the immense variety of subjects treated of i We recommend obstetrical students, young and 
and the grouud which they are madeto cover, the im old, to havf this volume in their collections. It 00 n 
possibility of giving an extended review of this truly ' tains not only a fair statement of thesigus, symptoibe, 
remarkable work must be apparent. We have not a i and disease? of pregnaucy, but comprises in addition 
single fault to find with it. and most heartily com. much interesting relative matter that is not to be 
mend it to the careful study of every physician. — found in an] other work that we can name — Edin- 
y Y. Med. J, urn., 1S70. burgh Med. Journal, Jan. IStJS. 



rPHE OBSTETRICAL JOUBXAL. {Free of postage/or 1878.] 

THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 

Including Midwifery, and the Diseases of Women and Infants. With an American 
Supplement, edited by J. V. Ingham, M.D. A monthly of about 96 pages, 

very handsomely printed. Subscription, Five Dollars per annum. Single Number- 
cents each. 
Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- 
ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; 
Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes. Edito- 
rial. Historical, Forensic, and Miscellaneous: Selections from Journals; Correspondei 
Collecting together the vast amount of ma terial daily accumulating in this important and ra- 
pidly improving department of medical science, the value of the information which it pre- 
sent* to t he subscriber may he estimated from the character of the gentlemen who have already 
promised their support, Including such names as those of Drs. A i in it.t . ROBBBT BaBHBS, H km: I 

Bknnkt, Thoyas Ceamberb, Fleetwood Cbitrchill, Matthews Di r< in, Grailt Hewitt, 

Braxton Hk-ks. Ai.khkh MbadOWS, W. Lrisiim \n, ALEX. SlHPBOK, TT1 I B BmiTB, B J 

Tii.t, SPBKCBB Wells, Ac. <fcc. ; in short, the representative men of British Obstetrics an . 
oology. 

In order to render the OBSTETRICAL JOURHAL folly adequate to the wants of the American 
profession, eaoh number contains a Supplement devoted to tbfi made in Obstet 

Gynaecology on this side of the Atlantic. This portion of the Journal is under the editorial 

ebarge of Dr J. V ls<rii\\i t0 whom editorial uin unicat mi,., ..\.i,.n 

view, etc., may be a Idressed, to the oare of the publisher. 

•** Complete sets from the beginning can no longer be furnished, bu: IB com- 

mence with Vol. V., April, I87T, or January, 181 



24 



Henry C. Lea's Pcbltcations — (Midwifery). 



pL AY FAIR ( W. &), M.D., F.R.C.P.. 

-*- Pmfetaor of Obstetric Medicine in King's College, etc. etc. 

A TRKATISK ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 

In one handsome octavo volume of 576 pages, with 166 illustrations : cloth, $4 00; lea- 
$5 00. (Just Issued ) 



tuer, 



student rind alflo the busy practitioner will rind 
here a rich mine from which he may oblain valuable 
information to aid him in his attendance on the pu*r- 
pe< al female The « hole chapter upon the management 
of a natural labor is by itsell worth the price of the 
book. Indeed, author- generally seem to regard this 
matter an of trivial importance, as though it were a 
thing too well known to need elucidation, while they 
dwell at great and tiresome length upon malpresenta- 
tions, malformationR, etc . matters which so rarely are 
encountered by the general prao'itioner But we might 
continue at <till greater length, so fascinating have we 
founi this hook ofDr Playfair's. We would earnestly 
recommend it to all our readers a* a hook which should 
1 prominent position on their shelves, and one, 
too. which they Bhould constantly and carefully study. 
— .!/• I, and 8 org. Reporter, Sept. 30, 1876. 

The author's reputation was sufficient to warrant 
great expectations, when Lis fo thcoming work was an- 
nounced, and its appearance has caused no disappoint- 
ment It deals iii a masterly way wiih many disputed 
points, and gives conclusions which it would be difficult 
to gainsay. The work is the most valuable acquisition 
to the subject on which it treats which lias been given 



'he profession in a Ion:: time, and in saying this we do 
not forget the man' admirable treatises which have re- 
' ently appeared. No practitioner can afford to be with- 
out it —Peninsular Joum. of Med., Sept. 1S75. 

The high reputation already won by Dr. Playfatr in 
this special depart ment of medicine is a sufficient guar- 
antee for the meritorious characterof this work. Every 
page is reple'e with interesting and instinctive matter, 
containing the very latest information regarding the 
subject of ob-t.-trics, full of hints of the greatest prac- 
tical value. This work will find, we predict, a large and 
ready sale The book is profusely illustrated with valu- 
able wood-cuts, and is printed in beautiful type. — Cin- 
cinnati Lancet and Observer. Nov. 1876 

This is pre-eminently a work adapted to the wants of 
students, and will do more towa d accomplishing the 
profession a* largein that particular branch of medicine 
than any other work in the field of obstetric literature. 
In praise of this work too much cannot be said— in ad- 
verse criticism very little. W'c advise every student 
and everv graduate to obtain it. and hope, ere longi to 
see it adopted as the principal text booK of obstetric 
medicine in every to 'lege in the United States. — Nash' 
ville Med. and Surg. Joum , Oct. 1870. 



TTODGE [HUGH L.), M.D., 

*~*~ Emeritus Professor of Midwifery, <V s. f in the University of Pennsylvania, Ac. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 

trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 



The work of Dr. Hodge is something more than a 
«lmple presentation of his particular views in the de- 
partment of Obstetric* ; it is something more than an 
ordinary treatise on midwifery ; it is, in fact, a cyclo- 
paedia of midwifery He has aimed to embody in a 
single volume the whole science and art of Obstetrics 
An elaborate text is combined with accurate and va- 
ried pictorial illustrations, so that no fact or principle 
Is left unstated or unexplained. — Am. Med. Times, 
Sept. 8, lsM 

It is very large, profusely and elegantly illustrated' 
and is fitted to take its place near the works of great 



obstetricians. Of the American works on the subject 
it is decidedly the best. — Edinb. Med. Jour., Dec. o4. 
We have read Dr. Hodge's book with great pleu 
sure, and have much satisfaction in expressing our 
commendation of it as a whole. It is certainly highly 
instructive, and in the main, we believe, correct. The 
great attention which the author has devoted to the 
mechanism of parturition, taken along with the con- 
clusions at which he has arrived, point, ve think, 
conclusively to the fact that, in Britain at least. th« 
doctrines of Naegele have been too blindly received. 
—Glasgow Med. Journal, Oct. 1864. 



**# Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 



ftAMSBOTHAM {FRANCIS H.), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 

CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, <fec, in the Jefferson Medical College, Philadelphia. In one large 
and handsome imperial octavo volume of B50 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 



QHURCHILL [FLEETWOOD), M. />., M.R.I. A. 

OX Till-] THEORY AND PRACTICE OF MIDWIFERY. A new 

American from the fourth revised and enlarged London edition. With notes and additions 
hv I). FraHCII <'om»ik., M. I)., author of> "Practical Treatise on the Diseases of Chil- 
dren." ,vo. With one hundred and ninety four illustrations. I n one very handsome octavo 

I .. -nil I .. _ I'MiL J. I AA . I ,il Jh r A A 



volume of nearly 701) large pages. (Mtlth, $4 00; leather, $5 00. 



'8TTIOW OF Till. SKSNS; IuaBY'8 SYSTEM OF MIDWIFERY. With Note« 
n\vv win, two .in.i additional Illustration* Seoond American 

'". I in r «■ lent- idttlon. One volnine octavo, cloth. 122 page*. 

In 1 rol.8TO.,Ol i p ,oloth. + *2 GO 



Henry C. Lea's Publications — (Midwifery. Surgery). 



25 



JjEISHMAN {WILLIAM), M.D., 

Regius Professor of Midwifery in the. University of Glasgow, &c. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second 
nnd Revised English Edition, with additions by John S. Parry, M.D., Obstetrician to the 
Philadelphia Hospital, Ac. In one large and very handsome octavo volume of over 700 
pages, with about two hundred illustrations: cloth, $5; leather, £6. {Just Issued.) 
That this book is recommended as a text-book by 

mauy of the hading scholars of medicine iD this 

country, is sufficient evidence of the favor In which 

it is held. In a. word we know of no betler book in 



oar language, both for the student and practitioner. 
The value of the book is enhanced by this second 
edition, which contains many notes by our late Dr. 
Parry.— Chicago Med. Journ. and Examiner, March, 
1877. 

But the most valuable additions to the volume are 
those made by the American editor. One of the best tests 
of a man's ability is for him to take a standard work in 
our profession, like this of Dr. Leishman. and materially 
improve it. Many a one, with more ambition than wis- 
dom, has attempted it with other books and failed. But 
Dr. Parry has succeeded most admirably. We know no 
obstetrical work that has anything better on the use of 
the forceps than that which Dr. Parry has given in this, 
and no work that has the rational and intelligent views 
upon lactation with which he has enriched this. Having 
used "Leishman" for two years as a textbook for stu- 
den ts, we can cordially comm end it. and are quite satisfied 
to continue such use now. — Am. Practitioner. Mar. 1870. 

This new edition decidedly confirms the opinion which 
we expressed of the first edition of the work, in the May, 
l-*?4, number of this Journal, that this is ' : the best 
moderu work on the subject in the English language." 



The excellent practical note? contributed by l>r I'arry 
refer principally to the nee of tin; forceps, lactation, and 
the puerperal diseases, and are intended to inci • 
usefulness of the work in this country. An cm. 
chapter <>u diphtheria of puerperal wounds I 
added (Dr. P. has had unu.-ual experience in this form 
of puerperal fever), and also a number of illustrations 
of the princi| al obsti trioal instrument* in nse in Ame- 
rica. We have no hesitation in Baying that the work, in 
its present shape, is a great, improvement on it.- prede- 
cessor, and in recommending it as the one obstetrical 
textbook which we should advise every English speak- 
ing practitioner and student to buy. — American Jour- 
nal of Obstetrics, Feb. 1870. 

Perhaps the most useful one the student can procure. 
Some important additions have been made by the editor, 
in order to adapt the work to the profession in this coun- 
try, and some new illustrations have been introduced, 
to represent the obstetrical instruments trenerally em- 
ployed in American practice. In it< present form, it is 
an exceedingly valuable book for both the student and 
practitioner. — New York Med. Jmcrnal, Jan. i EH 

In about two years after the issue of this excellent 
treatise, a second edition has been called for. We r»-_:;ird 
the treatise as thoroughly sound and practical, and one 
which may with confidence be consulted in any emer- 
gency.— The London Lancet, Dec. 11, lc76. 



JpARRY (JOHN S.), M.D., 

Obstetrician to the Philadelphia Hospital, Vice-Prest. of the 0\stet S^fiety of Philadelphia 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
Cloth, %1 60. {Lately Issued.) 
It is with genuine satisfaction, therefore, that we read out of something very like chaos. — Philadelphia Med. 
the work before us, which is far in advance of any mo- 
nograph upon the subject in the English language, and 
exceeding very much, in the number of ca-es upon 
which it is based, we believe, any work of the kind ever 
published. The author has given great care and study 
to the work.. and has handled his statistics with judg- 
ment; so ihat, whatever was to be gained from them, 
he has gained and added to our knowledge on the sub- 
ject. We owe the author much for giviug us a clear, 
readable book upon this topic. lie has. so far a< it is 
at present possible, removed the ob.-curity attending 
certain points of the subject. He has brought order 



out of something very like chaos. 
Tunes. Keb. 19, 1876. 

In this work Dr. Parry has added a most valuable 
contribution to obstetric literature, and one which meets 
a want long felt by those of the profession who have 
ever been called upon to deal with this class of cases. — 
B>ston Med. and Surg. Journ.. March 9, 1870. 

This work, being as near as possible a coUection of the 
experiences of many persons, will afford a mosi useful 
guide, both in diagnosis and treatment, for this most 
interesting and fatal malady We think it should be in 
the hands ot all physicians practi;riug midwifery.— Cm - 
cinnati Clinic, b'eu. 5, 1876. 



J^SHHURST [JOHN, Jr.), M.D., 

Prof, of Clinical Surgery, Univ of Pa., Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. In one 

very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, 
cloth, $6 50; leather, raised bands, $7 50. 
Its author has evidently tested the writings and I opinions of others He iscouservati ve, but not hide- 
experiences of the past aud present in the crucible 1 bound by authority. His style is clear, elegant, and 
of a careful, analytic, and honorable mind, and faith- scholarly. The w. rk is an admirable text-book, and 
fully endeavored to bring his work up to the level of a useful hook of reference. It la a credit to Am 
the highest standard of practical surgery. He is professional literature, and one of the first ripe fruits 
frank and definite, and gives us opinions, and gene- J >f the soil fertilized by the blood of oar late uu happy 
rally sound ones, instead of a mere restime of the I var. — N. Y. Med. Record, Feb 1, 18.72 



SKEY'S OPERATIVE SURGERY. In 1 vol. Svo. 
al., of 6f>0 pages ; withabont 100 wood-cots $3 2.*i 

COOPER'S LECTURES ON THE PRINCIPLES AND 
PractioeofSitrukry. In lvol. Svo cloth. 7">0 p. $2. 

GIBSON'S INSTITUTES AND PRACTICE OF NPK- 
'<krt. Eighth edition, improved aud altered. With 
thirty-four plates. In two handsome oc'avo vol- 
nines, about 1000 pp., leather, raised band' . *f W, 

THE PRINCIPLES AND PRACTICE OF SURGERY. 
By William Pirrib, f.k s i; , Profe»eor of Surgery 
in the University of Aberdeen, Edited by Johh 
Null, M.D., Professor of Surgery in the Penna 



Medical College, Surgeon to the Pennsylvania Hos- 
pital, &c. I n one very ha adsotne <>cia vo volume of 
788 pages, with 316 Illustrations, <•: 

Mil. I, KITS PRINCIPLES <>K BURGKRY. Fourth Ame- 
rican, from the Third Edinburgh Edition. In one 
large Rvo. vol, to - I" lllusti 

cloth, - 

MILLER'S PRACTICE of >1 RGERY Pourth Ame- 
rican, from the la*l Edinburgh tiditl 
the American editor. InoneUi r nearly 

TOO paged, 



H<stfRY C. Lea's Publications — (Surgery' 



6 'ROSS {SAMUEL D.), M.D., 
^ Profuaor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, 
carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In the 
present revision no pains have been spared by the author to bring it in every respect fully up to 
the day. To effect this a large part of the work has been rewritten, and the whole enlarged by 
nearly one-fourth, notwithstanding which the price has been kept at its former very moderate 
rate. " By the use of a close, though very legible type, an unusually large amount of matter is 
condensed in its pages, the two volumes containing as much as four or five ordinary octavos. 
This, combined with the most careful mechanical execution, and its very durable binding, renders 
it one of the cheapest works accessible to the profession. Every subject properly belonging to the 
domain of surgery is treated in detail, so that the student who possesses this work may be said to 
have in it a surgical library. 



We have now brought our tusk to a conclusion, and 
read :i work with the practical value ol 
which we hi »e been moreiraeressed. livery chapter is 
so concisely put together, that the busy practitioner, 
when in difficulty, can at once find the information he 
require*. His work, on the contrary, is cosmopolitan. 
the surgery of the world being fully represented in it. 
The work, in faet, is so historically unprejudiced, and so 
eminently practical, thai it is almost a false compliment 
to Bay that we believe it to he destined to occupy a fore- 
moat place as a work ofrefcreoce, while a system ofsur- 
,i ,,. present system of surgery is the practice oi 



Burgeons 



The prlntingand binding of the woTk is on- 
nable; indeed, it contrasts, in the latter re- 
spect remarkably with Ensrlish medical and surgical 
cloth bound publications, which are generally so wretch- 
edly stitched as to require re-binding before they are 
any time in use.— Dub. Joum. of AM. Set., March, 1874. 
Dr Gross's Burgery.a great work, has become still 
end merit, in its most recent form. 
The difference in actual number of pagers no tmore than 
130 bnt the size of the page having been Increased to 
what we believe iateebuically termed -elephant," there 

has l ro m for considerable additions, which, tog< - 

tber with the alterations, are improvements.— Land. 

. 1872. 

It eoml Ines, as perfectly as possible, the qualities of 

ook and work of reference. We think this last 

,. ,(,,,,, Surgery," will confirm his title of 



•' PrimttS inter Pares." It is learned, scholar-like, me- 
thodical, precise, and exhaustive. We scarcely think 
any living man could write so complete and faultless a 
treatise, or comprehend more solid, instructive matter. 
in the given number of pages. The labor must have 
been immense, and the work gives evidence of great 
powers of mind, and the highest order of intellectual 
discipline and methodical disposition, and arrangement 
of acquired knowledge and personal experience.— A'. Y. 
Med Joum., Feb. 1873 

As a whole, we regard the work as the representative 
"System of Surgery" in the English language. — St. 
Louis Medical and Surg. Joum., Oct. 1872. 

The two magnificent volumes before us nfford a very 
comple.e view ot the surgical knowledge of the day. 
Some years ago we had the pleasure of presenting the 
first editiou of Gross's Surgery to the profession as a 
work of unrivalled excellence; and now we have the 
result of years of experience, labor, and study, all con- 
densed upon thegreatwork before us. And to students 
or practitioners desirous of enriching their library with 
a treasure of reference, we can simply commend the 
purchase or these two volumes of immense research — 
Cincinnati Lancet and Observer, Sept. Ib72. 

A complete system of surgery — not a mere text-book 
of operations, but a scientific account of surgical theory 
and practice in all itsdepartmeuts.— Brit. and For.Mfd.- 
C/nr. Rev , Jan. 1878. 



r> 



Y THE SAME Al'THOR. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, 

and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third 
Edition, thoroughly Revised and Condensed, by Samiiim. \V. GrROSS, M !>., Surgeon to 
the Philadelphia Hospital, tn one handsome octavo volume of 574 pages, with 170 illus- 
trations: cloth, $4 50. (Just Issued.) 



The book is fully up to the times, and we know of no 

,, ,i, on the Bubjecl of urinary diseasi a that Is 

fuller and more complete than the one under notice;— 

r, Deo. l-7o. 

[tig a valuableand exhaustive treatise on the surgery 

. brought fully Dp to the existing 

„r knowledge A perusal ofitBK ii 

,:..;-.- PdC'JU Bled, a. it Surg. 

Nov. i ■'. '■. 
Nothin 5 need be nld to commend this standard wort 
to the proles Ion. It has long been considered one ol 

be pen of ti I tlnguished 

bs done bis work ably and faith- 

1 the ■ bapters, by do means the least 

pen; aa a mono rrapb repre- 

■ ,,- | ;;,i- mi which it treats, 

i i in our ' 



w.ii a mi Surg /.'<- 
|.-,, r ret ral Information, the ph 



or surgeon can find no work that meets their necessity 
more thoroughly than this, a revised edition of an ex* 
cellent treatise, and no medical library should be v, itb- 
out it. Replete with handsome lllustrati ns and good 

ideas, it has the unusual advantage Of being easily 

comprehended, by the reasonable and practical manner 

in WhlCh the various subjects are sy.-teinatizcd aid 
arran. c.l We heartily recommend it to the professil n 
a< a valuable addition to the imp.. riant literature i f dis- 
eases Of the urinary organs —Atlanta Mat /our n., Oct. 
1876. 

It is with pleasure we now ai;a in take up this old work 
In a decidedly nov dress. Indeed, it must he regarded 

as a new I k in very main of its parts. The chapters 

• a 'Diseases of the bladder," "Prostate Body," and 
'•Lithotomy," are splendid specimen* of descriptive 
writing; while the chapter on "Stricture" Is one of I he 
most concise and clear that we have ever read— A- 1* 
(fed, Joutn., Nov. i.sTti. 



j,) Till- SAME AUTHOR. 

'a PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

A1H PASSAGES. In I vol. Hvo., with illustration, pp. 468, cloth, $2 76. 



Ii 



IOELOW [HENRY J.), M. />., 

or of Surgery in tnt Mat&aonnHtts MSmS, Qott*g% t 

ON THE MECHANISM OF DISLOOAT] 



NIK MECHANISM OF DISLOCATION AND EHACTURE 

imp; HIP. With tbe EUd notion of the Dislocation by the Flexion Method. With 

il UloitratiODI. In one very handsome octavo volume. Cloth, $2 . r >o 



01 

numerous 



Henry C. Lea's Publications — (Surgery). 



21 



OTJMSON (LEWIS A ). A.M., M.D., 

^-3 Surgeon to the Preshyterim Hos/jitol, to Vt° Nero York Dig) < usury, *•?. 

A MANUAL OF OPERATIVE SURGERY. In one very hands 

royal 12mo. volume of about 500 pages, with over 300 illustrations. (/ 

early Publication ) 
Many years having elapsed since the appearance in this country of any work devoted exclu- 
sively to the operations of surgery, and the ordinary surgical text-books being too large and 
urwieldy for ready consultation and reference, the author has thought that u compact manual 
devoted exclusively to practical operative details, thoroughly illustrated would supply B want 
universally felt. He has accordingly sought to embody LB the work a concise account of all the 
operations practised at the present day, devoting special attention to the newer and less fami- 
liar ones, copiously illustrated with diagrams and figures, many of which are original. The 
scope of the work can be gathered from the subjoined very condensed 

STJlVrnVTAIRY OF COTSTTENTS. 
Part I. The Accessories of an Operation. Part II. Lioatcre of Arteries. Part III. 
Amputation. Part IV. Excision ok Joints and Bonks Part V. Xii Rotomr and Tebjot- 
omv. Part VI. Plastic Operations of the Face. Part VII. Special Operations. I 

7. Operations upon the Eye and its Appendages. Chop. II. Operations upon the Ear and its 
Appendages. Chop III Operations upon the Mouth and Pharynx. Choj>. IV. Opera! 
performed upon the Neck. Chop. V Operations performed upon the Thorax. Chap. VI. Ope- 
rations performed upon the Abdominal Wall, Stomach, and Intestines Chop. VII Operations 
upon the Male Genito-Urinary Organs Chop. VIII Operations upon the Genito- Urinary 
Organs of the Female. Chop. IX. Miscellaneous Operations. 

JJOLMES [TIMOTHY), M:&., 

Surgeon to St George's Hospital, London. 

SURGERY, ITS PRINCIPLES AND PRACTICE. In one band- 

some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6; leather, $7. 
{Just Issued.) 

We Relieve it to be by far the best surgical text-book 
that we have, insomuch as it is the completed, and 
theoiie most thoroughly brought np tothe knowledge 
of the present day. All who'will give this book the 
careful perusal that it de-erves aud requires, -whe- 
ther student or practitioner, will agree with us, thut, 
from the happy way iu which justice is done, both to 
the principles and practice of surgery, from the care 
with which its pages are brought up to modern date, 
from the respect which is paid all along tn the opin- 
ions of others, it deserves to take the first place 
among the text-booka on surgtry. — British Med. 
Journ., Dec. 2a, 1S75. 

This is a work which has been looked for on both 
si.les of the Atlantic with much interest. Mr. Holmes 
is a surgeon of Urge and varied experience, and one 
of the best known, and perhaps the most brilliant 
writer upon surgical subjects in England. I 1 is a 
book for students — and an admirable one — and for 
the busy general practijouer It will give a student 
all the knowledge needed to pass a rigid examina- 
tion. The book fairly jiistifiesthe high expectations 
that were formed t»f it. Its style is clear aud forcible, 
even brilliant at times, and the conciseness needed 



to bring it within its proper limits has not impaired 
its force and distinctness.— y. V. Med. Record April 
14, 1*76; 

It will be found a most excellent epitome of sur- 
gery by the general practitioner who has not the time 

I togiveattention to more minateand extended work-, 
and to the medical student. In fact, we know of no 

| one we cau more cordial y recommend. The author 
has succeeded well in giving a plaiu and practical 

| account of each surgical iujury an.: nd of 

I the treatment which is most commonly advisable 
It will no doubt become a popular work in the pro- 
fession, and especially as a text-book.— Cincinnati 
Med. Nr-ws, April, 1S06. 

In point of literarv structure we have no words but 
those of praise to write of Dr. Holmes's book His 
diction is always graceful and clear, and he 
w.»rks with great conscientiousness. There ii- much 
independence of thought and a healthy disposition to 
resist the tendency to walk iu old tracks »implv be- 
cause they are old. On ihewhole, behaedonehis work 
in a manner for which it would be ungenerous not to 
give him very high credit indeed —Dublin Journ nt 
Med., Oct. IS 76. 



H 



r AMILTON {FRANK H.), M.D., 

Professor of Fractures and Dislocations, Ac, in Bellevue. Hosp. Med College New York 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 

T /° NS ; <£\ fth edltlon ' "vised and improved. In one large and handsome octavovoluire 
of nearly 800 pages, with 344 illustrations. Cloth, $5 75 ; leather, $6 75. ( L 
This work is well known, abroad as well as at home, as the highest authority on its important 
sub.|eot-an authority refogm/.ed in the courts as well as in the schools and in practice—and 
again manifested not only by the demand for a fifth edition, hut by arrangements now in pro- 
gress for the speedy appearance of a translation in Germany The repeated revisions which the 
author has thus had the opportunity of making bare enabled him to give the mostoareful consid- 
eration to every portion of the volume, and he has sedulously endeavored in the preaenl 
to perfect the work by the aid of his own enlarged experience and bo incorporate in it whatever 
of value has been added in this department since the issue of the fourth edition It will there 
fore be found considerably improved in matter, while the most careful attention has been paid 
to the typographic:-! execution, and the volume is presented tothe profession in the confident 
hope that it will more than maintain its very distinguished reputation. 



Therein no belter work on the subject in existence 
than thai of Dr. Hamilton, it should be In the 
pion of every general practitioner and 
Am. Journ. of ObsU tries, Feb ls7o. 

The value of a work like this to the practical phjwl- 
nan and surgeon can hard I j be over-estimated and the 
necessity ol having such s book revioed to the latest 
dates, not mer. lyonaeoount of the praotioal Importance 



ihlngs, hut also by reason of tn • 
bearings o1 the canes of which li tr 

■ d«mu the Buhject ol useful p«| - 

ton and | iientlj obvl 

prenenl rolum 

recommend it a* t ; „,„.| |„ 

the Koglinh language, and nol excel le I h 



L'> 



Henry C. Lea's Publications — (Surgery^. 



FRICHSEX {JOHN E.), 

■U Professor of Surgery in University College, London, etc. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 
gical Injuries, Diseases, and Operations. Carefully revised by the author from the 
Seventh ana enlarged English Edition. Illustrated by eight, hundred and sixty two en- 
gravings on wood. Id two large and beautiful octavo volumes of nearly 2000 pages : 
cloth, $8 50 ; leather, $10 50. {Now Ready.) 
" I have endeavored to mike this edition of ' The Science and Art of Surgery' more deserving 
than those which preceded it have been of the favor accorded to them by the surgical profession 
of the United States of America. In consequence of unavoidable delay in the publication of 
the Seventh British Edition, I have lound time to add to this one several paragraphs on im- 
portant practical subjects, which will, I trust, be found to enhance the utility of the work as a 
guile to the practitioner of surgery. I dedicate these volumes to the surgical profession of 
the United States of America, in testimony of the esteem which I entertain for that large 
and enlightened body of practitioners, and of the cordial friendship that exists between me and 
many of its members." — Author's Prkfack to the New American Edition. 

In revising this standard work the author has spared no pains to render it worthy of a continu- 
ance of the very marked favor which it has so long enjoyed, by bringing it thoroughly on a 
level with the advance in the science and art of surgery made since the appearance of the 
iition. To accomplish this, has required the addition of about two hundred page" of text, 
while the illustrations have undergone a marked improvement. A hundred and fifty additional 
wood cuts have been inserted, while about fifty other new ones have been substituted for figures 
which were not deemed satisfactory. In its enlarged and improved form it is therefore pre- 
sented with the confident anticipation that it will maintain its position in the front rank of 
text-bocks for the student, and of works of reference for the practitioner, while its exceedingly 
moderate price places it within the reach of all. 
Of the manv treatises on Sorcery which it has been new ones have been added, and many of the old cm : 



our task to >tii'ly. or our pleasure to read, there is none 
Which in all points Las satisfied us so well as the classie 
treatise of Ericbsen. His polished, clear style, his free- 
dom from prejudice and hobbies, bis unsurpassed grasp 
(,'. hi> subject, and vast clinical experience, qualify him 
admirably to write a model text-book. When we wish, 
at the least cost of time, to learn the most of a topic in 
surgery, we turn, by preference, to his work. It is a 
pleasure, therefor'?, t"> see timt the appreciation of it is 
general, and has led to the appearance ofanoi her edition. 
— Mil . and Surg. Reporter, Feb. 2, 1878. 

Notwithstanding the increase in size, we observe that 
much old matter has been omitted. The entire work 
has been tb iroughly written up. and not merely amend- 
ed bj n fe » extra chapters a great improvement lia* 
been made in the il.ustratious. One hundred and titty 



have been redrawn The author highly appreciates the 
favor wiih which his work has been received by Ameri- 
can Surgeons, and has endeavored to render his latest 
edition more than ever worthy of their approval. That 
he has succeeded admirably, must, we think, be the 
general opinion. We heartily recommend the booh to 
both student and practitioner. — N. Y. Med. Journal, 
Feb. 1878. 

It is entirely unnecesrary for us to attempt to add. by 
our praises, one jot to the established reputation of 
Kricbsen's Science and Art of Surgery. It has long 
been a 1'avorite text-book and authority in this country 
as well as in England and on the Continent, and the 
present edition can hut add to its popularity.— Ohio 
Med, lit corder, Jan. 1878. 



T)RUITT {ROBERT), M.R.C.S., frc. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition. Illus- 
trated with four hundred and thirty -two wood engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 

practice of surgery are treated, and so clearly and 
perspicuously, as to elucidate every importa,u t topic. 
We nave examined the book most thoroughly, and 
can my that this success is well merited. His book, 
moreover, possesses the inestimable advantages of 
having the subjects perfectly well arranged and alas- 
^ifled, and of being written in a style at once clear 
ind succinct.— Am. Journal of Me<i. Scit n 



All that the surgical student or practitioner could 
d »«ire.— Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure. — 
Boston lied, and Surg. Journal. 

In Mr. Drttltt's book, though containing only some 
»even hundred pages, both the principles and the 



WSSEL1N (L.), 

Profi tsor of Surgery in tht faculty of Medicine, Paris, etc. 

CLINICAL LECTURES ON SURGERY. Delivered at the Hospital 

ol La Charite. Translated from the French by Lewis A. Stimsow, M I)., Burgeon bo the 
Presbyterian [Iospital, New York. With illustrations. [Publishing in the Medical N*uh 
and Li rary, commencing with the July No. 187(*>.) 



B 



II V A XT (THOMAS), F.R.C.S., 
Burgeon to (Jug's Hospital. 

THE PRACTICE OF SURGERY. With over Five Hundred En- 

graving! OB Wood. In one large and very handsome octavo volume of nearly 1000 pagef, 
Oloth, $6 26 j bather, raise. I bands, $7 25. (Lately Puiluhsd.) 

BARGBNTON BANDAGING AND OTHER OPEBA- 
TION8 OP MINOR 8UROBRY New edition, with 

km :oi.ht ai obapter on Military Bnrgery One 

I2mu eel. ol 383 pages, with 181 wood-outs. Cloth. 
*t 75. 



, OB Till. DISEASES INJURIES, AND mal- 
um KEI H M UN DAN I 

-i i tip lUwD Bl OOOd A ni.-ri- 

■ .. i London Bdltloo 
I i. oqs E • 



Henry C. Lea's Publications — ( Ophthalmology). 29 



TjROWNE [EDGAR A.), 

f} tiro eon to the Liv*rpoo> E>/e aw> *?/»r Infirmary, and t' the Dispensary for Shin DiMfOSes 

HOW TO USB THE OPHTHALMOSCOPE. BeiDg Elementary In- 

structions in Ophthalmoscopy, arranged for the Use of Students. 'W ith thirty fire 

tions. In one small volume royal 12mo. of 120 pages : cloth, $1. (Row lxeaiiy.) 

Nothing could be more clear and simple than Dr. ev i y medical student, and w- had almost said every 

Biowne's description of the ophthalmoscope, and general practitioner. Ite expla nation of the 

the best means of acquiring facility in its use. The principles on which the opblhalmosci 

chapter on optical yrincipbs is excellent, and is is to clear and simple that the most stupid reader 

aided very much by the abundant illustra.ions. — could scarcely fail of understanding them. Equally 

If. Y. Med. Journ., Dec. 1S77. satisfactory are the directions for the use of tie in- 

This is a useful little volume to the student begin- s,|l|llltlU » nd ,l , h >"^--t' ns to aid in inlet 

ning to use the ophthalmoscope. It supplies the what is seen -iMroi* Ved. Journ., S»v. \i 
place of an instructor, and calls attention to many We congratulate the author on so successfullj accom- 

important and practical points which one not skilled plfching hi* object, and recommend the In ok to all stu- 

in the examination of the eye would he likely to pass dents interested in this particu ar line of studs.— Mt I 

by carelessdy. If*is quite evident -hat the author and Surg. Reporter, June 2, 1877. 
understands the acquirements of a good oph hah.io- The information is given hi a veircondse, but we may 

scopist, and also the steps necessary to his best de- itl , 9 „ a ,id. in a verj clear and Ibnible manner Manj i>f 

yelopment —Archives of Can. Surgery, inns 15, the diagrams thai illustrate the text are ,ii_ , 

toil. 



This capital little work should be in the hands of 



ingenious in t) eir construction, and very iu.-tru 
Med. Journ. 



ffARTER (R. BRUDEXELL), F.R.CS., 

v-^ Op'itfialn ic Surgeon to St George s Bo*pUal, (to. 

A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 
ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one 
handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Jn$t 
Issued.) 
Dr. Green, whose reputation and experience in this department are well known, has given this 
work a very careful revision, and has introduced much matter which will be found of importance 
to the practitioner. As his system of test-types i.s the one recommei ded by the author, they 
have been inserted in the volume in a shape which will admit of their being detached and 
mounted for convenient office use. 

These test-types, on a sheet for mounting, can be had separate, price 25 cents. 
It would be difficult for Mr. Car er to write an uniu- in view, and presents the subject in a clear and coueise 
structive book, and impossible for him to write an un- I mauner, easy of comprehension, and heme the no re 
iuterestiug one. Even on subjects with which he is not ! valuable. We would especially commend, however, as 
bound to be familiar, becan discourse with a rare degree i worthy of high praise, the manner in wbicn tne there- 
of clearness and effect. Our readers will therefore not j peutics of disease of the e^ e is elaborated, for bore tl e 
be surprised to learu that a work by him on the Diseases j author is particularly clear aud practical, where other 
of the Bye makes a very valuable additiou to oph thai- writers are unfortunately too often deficient. The final 
mic literature. . . . The book will remain one useful chap.er is devoted to a discussion ot the uses and selec- 
alike to the general and the special practitioner. Not j tion of spectacles, and is admirably compact, i lain, aud 
the least valuable result which we expect from it is that useful, especially the paragraphs on the treatment ul 



it will to some considerable extent despecialize this bril- 
liant department of medicine. — London Lancet, Oct. 30, 
18T5. 

It is with great pleasure that we can endorse the work 
as a most valuable contribution to practical ophthal- 
mology. Mr. Carter never deviates from the end be has 



presbyopia and myopia. In conclusion, our thanks an 
due the author for many useful hints in the gr< 
ject of ophthalmic surgery and therapeutics, 
where of late years we glean but a I sound 

wheat from a mass of chaff — Ai w Y'ork Medical Recot U. 
Oct. 23, 1875. 



WELLS {J. SOELBERG), 

* * Professor of Ophthalmology in King'' 8 College Hospital, &c. 

A TREATISE ON DISEASES OF THE EYE. Second America! , 

from the Third and Revised London Edition, with additions ; illustrated with numerous 

engravings on wood, and six colored plates. Together with selections from the Test-type? 

of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 

pages; cloth, $5 00; leather, $6 00. {Lately Published.) 
On examining it carefully, one is not at all sur- lucid and Bowing, therein differing materially from 
prised that it should meet with universal fav«»r. It someof the translationsof Continental writereombis 
is, in fact, a comprehensive and thoroughly practical subjects that are in the market. Special pa - 
treatise on diseases of the eye. setting forth the prac- taken to explain, at length, those 8 objects which ate 
tice of the leadiug oculists of Europe and America, particularly difficult of comprehension 
frudgivingthaaatbor'sownopinionsand preference*, aer, as. the use of the ophthalmoscope, the Interpre- 
wbicb are quite decided and. worthy of high coosid- tation of its images, etc. The bo $ely»ud 

eration. Tne third English edition, from which this ab y Illustrated, and al tl 
Is taken, having been revised by the author, com- excellent colored ophthalmoscopic flgur 

prises a notice ot all the mote receut advances made eopies of some of the plates in. Lie 

iu ophthalmic science. The style of the writer is atlas.— Kansas City M>d. Joum., June, 16 



'A URENCE [JOHN Z.), F. R. C. S., 

Editor of the Ophthalmic Rcvieto, Ac. 

A HANDY-BOOK OF OPHTHALMIC BURGERY, for the use i i 

Practitioners. Second Edition, revised and enlarged. With numerous illustrations. I n 
one very handsome octavo volume, cloth. $2 75. 



A WSON {GEORGE), F. h'. C.S., Engl., 

Assistant Surgeon to th, Roy al London Ophthalmic R rJUUU *c 

INJURIES OF THE EYE, ORBIT, AND EYELIDS: their In 

diate and Remote Effects. With about one hundred illustrations. In one 
some octavo volume, cloth, $3 oO. 



10 



Henry C Lea's Publications — (Medical Jurisprudence y . 



ftCRXETT (CHARLES II), M.A , M.D., 

-*-' Aural Surg to the Pre*©. Hemp., Surgeon-in-ihargeof the Fnfif forDis. of the Ear, Phila. 

THE EAR, ITS ANATOMY. PHYSIOLOGY, AND DISEASES. 

A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
some octavo vo'ume of 615 pages, with eighty-seven illustrations : cloth, $4 50; leather. 
50. {Just Ready.) 
Recent progress in the investigation of the structures of the ear, and advances tna^e in the 
modes of treating its diseases, would seem to render desirable a new work in which all the re- 
sources of the most advanced science should b« placed a* the disposal of the practitioner. This 
it has b^en the aim of Dr Burnett to accomplish, and the advantages which h' has enjoyed in 
tiie special study of the subject are a guarantee that the result of his labors will prove of service 
to the profession at large, as well as to the specialist in this department. 

As the t tie of the work indicates, this volume | the medical studeut and general practitioner, this 



Dl the anatomy and physiology of the ear, as 

ml the author has taken 

spe-ial pains to matce this difficult and complicated 

matter thoroug md intelligible The book 

lly t'.>r the use of students and 

general practitioners, and places at their disposal 

much valuable m aerial. Buoh a book as the pre- 
•>. we think, ha> long been needed, am\ we 
igratulate the author an his success in fill- 
ing the gap Both Student and practitioner can 
-tidy the work with a gr«at deal of benefit. It is 
prjfu-ely and beautifully illustrated.— N. F. Hot- 
Gazette, Oct 15, 1677. 
The medical student and general practitioner 
hive long felt the need of a book of this character on 
. m so little understood and yet so important 
as the ear. Theauthorhas presented m tic volume 
clearly but ooncioely the great advances which have 
de of late years in otology and has indicated 
the direction iu which further researches can be 
most profitably carried ou The work is divided 
into two par.s. 1 ii Part I. the anatomy and physiol- 
ogy of the ear ar<? minutely, yet explicitly, detailed 
In a manner not ifl be found in any of the ordinary 
text-books. Jo Part 11 the diseases and treatment 
ar are fully and practically pte.-euied. To 



work is indispensable, and will not be found void of 
iuterest to the specialist — Maryland 3Itd. Journ., 
Nov 1S77 

The appearance of this book is another proof of the 
rapidly increasing amouut of honest, valuable work 
that is now being done in the various branches of 
medical science in this country Dr. Burnett is to be 
commended for having written the best book on the 
subject iu the English language, and especially for 
the care and attention he has giveu to the scientific 
side of the subject.— N. Y. Med Journ., Dec. 1S77. 

There is probably no other book of the kind iu 
the English language which contains so concise and 
yet so complete an account of the numer ms dis- 
eases to which the <-ar is liable. We can safely pre- 
dict that every intelligent medical man who takes 
the trouble to make himself f miliar with tho lead- 
ing facts concerning this class of disease, as given 
by Dr. Buruett, will not only admit that the time 
thus employed was far from being wasted, but that 
the earnest labors of Otologists within the last few 
years have taken away l he sting of reproach con- 
tained in the hackneyed phrase that' nothing can 
be got out of the ear but fee- and wax."- Canada 
Med. and Surg. Journ., iN'ov. ls-77. 



/TAYLOR {ALFRED S.), M.D., 

■*■ Lecturer on Med. Jurl&p. and Chemistry in Guy' s Hospital . 

MEDICAL JURISPRUDENCE. Seventh American Edition. Edited 

by John J. Reese, M.D., Prcf of Med. Jurisp. in the Univ. of Penn. In one large 
octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. {Lately Issued.) 
To the members of ( he legal aud medical profession, , in behalf of a work on medical jurisprudence by an 

: . i „ . , , ...... i. . ~ „...]... e i .... ti. .... ~i. . ; . .. 1 ........ .<. ., i „., n'„ ... t ....... ...I , .. I... il,» 



it is unnecessary to say anything commendatory of 
- Medical Jurisprudence. We might as well 
undertake to Bpeak of the Mierit of Chitty's Plead- 
ings.— CV/iVv^/o Legal NetOS, Oct. 16, 1S7S. 

Little can be added to what has already been said 

of this standard workof Dr. Taylor's. Asa manual 

opreheasive extant, meet 



author who is almost universally esteemed to be the 
best authority on this specialty iu our language. On 
this point, however, we will »ay that we consider Dr. 
Taylorto be the safest medico-legal authority to fol- 
low, in general, with which we are acquainted in any 
language.— Fa Clin. Record. Nov. 1S78. 



ing fully the demands of the atudent of medicine] Thislastedition oftheManual is probably the best 

and law — Western Lancet, Nov I 78 of all, as it contains more material and U worked np 

,, to the latest views of the author as expressed iu the 

[t Is beyond question the mosl attractive as well Last edition of the Principles. Dr. Reese, the editor 

"''' Jurisprudence of the Mammi. has done everything to make his 

published In the English language.— Am. Journal ^ rk aooeptable to his medical oountrymea.-tf. F 

of Byphih graphy, Oct. 1.873 )Id Hecurdt Jau . l5j l874< 
It Is altogether superfluous for us to offer anything 

J>Y THE SA)lh AUTHOR. 

THE PRINCIPLES A M) PRACTICE OF MEDICAL JURISPRU- 

DENCE. Seoond Edition, Revised, with numerous Illustrations. In two large octavo 
volumes, cloth, $10 00j leather, $12 00 

Tin •• recognised in Bngl&nd as the fullest and most authoritative treatise on 

ever) department ol its important subject. In laying it, in its improved form, before the Ameri- 
can profession, the publisher trusts that it will assume the same position in this country. 

j>) THE nm//. AUTHOR {Neu Edition— Ju*t Issued. ) 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE A NB 

MEDIl rNE Third American, fronftthe Third and Revised English Edition. In one 

Oioth, S-> 5<> ; leather, $(i G>0. 



ol medical profe ilon 

I ■ • '. 

n B M ■• ii, 

dertaki I h< mei ll ol Obit) 

i- probablj the be I 

ed ui> to 
ad in tin' last 



•• iiMon oi "the Princlplei" Dr. P -• n di tor of the 

Manual, has done everything to make bin work accept* 
i i'l<- to hi- medloal country men. - A'ew Yorh 

J in i... is; i 
It i- beyond question the most attractive a* well tie 

lable manual ofmedlcaljurlspruden re published 
in the Bn flish Imerican Journal of Spphilo- 

graphy Oci I 



Henry C. Lea's Publications — (Miscellaneous), 



31 



rPHOMPSON {SIR HENRY), 

■* Surgeon and Professor of Clinical Surgery to University Coltege Hospital . 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 
octavo volume. Cloth, $2 25. {Just Issued.) 

T>Y THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHKA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
{Lately Published.) 



B 



Y THE SA ME A UTHOR. 

THE DISEASES 

AND TREATMENT. 



OF THE PROSTATE, THEIR PATHOLOGY 

Fourth Edition, Revised. In one handsome i>\ o. vol. 
with 13piates, plain and colored, and ill ustrations on wood. Cloth, $3 75. {Just i- 



rPUKE {DANIEL HACK), M.D , 

J- Joint author of " The Manual of Psychological Medicine," &c. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 

Imagination. In one handsome octavo volume ol 416 pages, c.oth, $3 25. {Laltiy Issued.) 

J1LANDFORD {G. FIELDING), M. D., F. R. G. P., 

•*-* Lecturer on Psychological Medicine at the School of St. George's Hospital, Sec. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
handsome octavo volume of 471 pages; cloth, $3 25. 
It satisfies a want which must have been sorely actually seen in practice and the appropriate treat- 
ment tor them, we hnd in Dr. Blandford's work a 
considerable advance over previous writings on the 
subject. His pictures of the various forma of mental 
disease are so clear and good that uo reader can tail 
to be struck with their superiority to those given in 
>rdinary manuals in the English language oi 
as our own reading extends; in any other.— London 
Practitioner, Feb 1871. 



felt by the busy general practitioners of this country. 
It takes the form of a manual of clinical description 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call particular attention to this feature 
of the book, as giving it a unique value to the gene- 
ral practitioner. If we pass from theoretical conside- 
rations to descriptions of the varieties of insanity as 



f EA {HENRY CO- 
SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, 

Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; cloth, ?J 7b, 

{Lately Published.) 

We know of no single work which contains, in so i interesting phases of human society and progress. . 

*mall a compass, so much illustrative of thestrangest j The fulness and breadth with which he has carried 

operations of the human mind. Foot-notes give the ! out his comparative survey of this repulsive held on 

authority for each statement, showing vast research j history [I'ouureJ, are sucn as to preclude our do.uj 

and wonderful industry. We advise our confreres justice to the work within our present limits. Dm 

to read this book and ponder its teachings. — Chicago ' ' 



Med. Journal, Aug. 1870 

As a work of curious inquiry on certain outlying 
points of obsolete law, •• Superstition and Force'' is 
one of the most remarkable books we have met with 
—London Athtnteum, 2\ T ov. ;i, 1866. 

He has thrown a great deal of light upon what must 
be regarded as one of the most instructive as well as 



here, as throughout the vol me, tUere will be found 
a wealth of illustration and a critical grasp ol the 
philosophical import of iaets which will render. Mi. 
Lea's labors of sterling value to the historical stu- 
dent. — London Saturday Rr.citto, 0< 

As a book of ready refereuce on the subject, it is of 
the highest value. — Wr.sl minster Review, Oct. 1867. 



B 



Y THE SAME AUTHOR. {Late y Published.) 

STUDIES IN CHURCH HISTORY— THE RISE OF THE TBM- 

POUAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 
12mo. volume of 516 pp.; cloth, $2 75. 

literary phenomenon that the head of one of the firM 
.i houses i- also the writ< i 

Original bOOkB. — London Atht nattin. Jau. 7. 1871 

Mr. Lea has done great honor to himself aud thu 
country by the admirable works be hi- wntteu on 
eeclesiologicaland oo 

bad occasion to command in- u .»ud 

Force" and his " El 
The present volume i- ful 



The story was never told more calmly or with 
greater learning or wiser thought. We doubt, indeed, 
If any other study of this held can be compared with 
this for clearness, accuracy, and power. — Chicago 
Examiner, L>ec. 1870. 

Mr. Lea's Latest work, "Studies la Church History," 

fully sustains the promise of the nrst. It deals with 

three subjects — the remporal Power, i^'ueflt of 

Clergy, and Bxoommadloation, the record of which 



ouliar importance for the English student, and thod of dealing with topic- and m the tfa 

Is a ohapter on Ancient Law likely to be regarded as a quality so frequently ... - 

Anal. We can hardly pass from our mention ofeuob with which they i r.> i u >.-.•-■ 

works as these— with which that on "Sacerdotal Peyohoi IferfioitM, July 

Celibacy" should be Included— without uotius the 



32 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE. 



-ican Journal m( the Medical Sciences 
Monthly, of the Med. Science* 

Alien':- Anatomy ...... 

Anatomical Atlaa, by smith and Horner 

A-htoD on the Rectum and Anus . 

Attneid's Chemistry 

Ashwell on Disease- of Females . 

Aahhurat's Surgery 

Browne on Ophthalm isc< pe , 

Burnett on the Eur ..... 

Barnes on Diseases of Women 

Bellamy's Surgical Anatomy 

Bryant's Practical Snrgery . 

Bloxam's Chemistry .... 

Blandford on Insanity .* 

Bdshain on Keual Diseases . 

Brinton on the St. 'math 

Bigelow on the Hip .... 

Barlow's Practice of Medicine 

Bowman's (John E.) Practical Chemistry 

B twman's (John E ) Medical Chemistry 

Bristowe's Practice .... 

tSumstead on Venereal .... 

Bnmetead and Cullerier's Atlasof Venereal 

Carpenter's Human Physiology . 
Carpenter on the Use and Abuse of Alcohol 

Carter on the Eye . . • . 

Clelaud's Dissector .... 

Clowes' Chemistry . 

Century of American Medicine 
Chambers on Diet and Regimen . 
Chambers's Restorative Medicine 
Christison and Griffith'.- Dispensatory 
Churchill's System ol Midwifery. 
Cnurchill on Puerperal Fever 
C judie on Disease- nf Children . 
Cooper's (B. B ) Lectures on Surgery . 
Callerier's Atlas of Venereal Diseases 
Cyclopedia of Practical Medicine. 
Dalton'6 Human Physiology 
Davis's Ciiuicai Lectures 
Dewees on Diseases ol Females 
D mitt's Modern Surgery 
Dunglison's Medical Dictionary . 
Dangllson's Human Physiology . 
Erich-en's System of Surgery 
Farquharson's Therapeutics . 
Fen wick's Diagnosis .... 
Flint on Bespiratory Organs . 

Flint on the Heart 

Flint's Practice of Medicine . 

Flint's Essays 

Flint on Phthisis 

Fliut on Percn«jnl >n .... 

• ■, gill's Handbook ofTreatment . 
P'twuBJi's Elementary Chemistry . 
E »I on Dl • -kin . 

Puller on the Lui 
Oreen'c Pathology and Morbid Anatomy 

n's Borgery 

(J l uk' jy, by Leidy 

■ Anatomy 
Griffith's (B. 1 i Formulary 

. 
d Air-Passages 
■ of Burgery 
I-. - on -11 gery 
Bamilton on Dtsl< Fraci tirei 

■ Dtla 1- <>i Medicine . 
ll irt- ■ of the Med 

Harl ogy 

. 
mj . . 



Bolland'i H< lefleotloBi 

Hold* ... 



Tomer's Anatomy and Histology 

II nlson on Fever ..... 

lill on Venereal Diseases 

iillier's Handbook of Skin Diseases 

rones (C. Haudneld) on Nervous Disorde 

Kirkes' Physiology .... 

Knapp's Chemical Technology 

Lea's Superstition and Force 

Lea's Studies in Church History . 

Lee on Syphili 



29 
30 

-'z Lincoln on Electro-Therapeutics 
j Leishman's Midwifery . 
•° La Koche on Yellow Fever 
La Roche on Pneumoi 



&c. 



» Laurence and Moon's Ophthalmic Surgery 

'• Lawson on the Eye 

*■ Lehmann's Physiological Chemistry, 2 vol 

-' Lehmann's Chemical Physiology . 

,■; ! Ludlow's Manual of Examinations 



: Lyons on Fever 
I Medical News and Library 
Meigs on Puerperal Fever 



■ Miller's Practice of Surgery . 
■^ Miller's Principles of Surgery 

~ Montgomery on Pregnancy . 
*jj Neill and Smith's Compendium of Med Science 
2 X I Neligan's Atlas of Diseases of the Skin 

* Obstetrical Journal 
l \ Parry on Eitra-Uterine Pregnancy 

5 Pavy on Digestion .... 

J? jPavy on Food 



Parrish'6 Practical Pharmacy 
2 Pirrie's System of Surgery . 



l.'S 

%* I Playfair's Midwifery .... 

~ Quain and Sharpey's Anatomy, by Leidy 

"\ Roberts on Urinary Diseases . 

~~ Ramsbotham on Parturition 

*■* Remsen's Principles of Chemistry 



I Rigby's Midwifery 



. Rodwell's Dictionary of Science 
14 Siii 



im6on s Operative Surgery 
Swayue's Obstetric Aphorisms 



! Sargent's Minor Surgery 



iSharpey and Quain's Anatomy, by Leidy 
Skey's Operative Surgery 
Slade on Diphtheria .... 
Schafer'a Histology .... 
Smith (J. L.) on Children 

Smith hi. H.) and Horner's Anatomical Atlas 
|? Smith (Edward) on Consumption . 
•' Smith on Wasting Diseases in Children 
-tille's Therapeutics 
Stilly & Malsch's Dispensatory 
Sturges on Clinical Medicine 

Stokes on Fever 

Tanner's Manual of Clinical Medicine . 
Tanner on Pregnancy 



Taylor's Medical Jurisprudence 

Taylor's Principles and Practice of Med J 

Ta\ lor >in Poisons . 

Tuke on the Influence of the Mind 

rhoinas on Diseases of Females 

Thompson on Urinary Organs 

I'lioiiip-on on Stricture . 

Thompson on t he Prostate 

["odd '»u Acute Diseases • 

Walske on the Heart 



Watson's Practice ol Physic 

Wells on the Eye . 

West on Diseases Of Females 

West cm Diseases of Children 

w.-t on Nervous Disorders of Childre 

What to Observe in Medical Cases 

Williams on Consumption 



i- Wilson's Human Anatomy 



Wilson cm Diseases <>f the Skin . 
Wilson's Plates on Diseases of the Skin 
Wilson's Handbook <>r Cutaneous Medicine 
Wiihler's Organic Chemistry 
Winokel oh Childbed . 



risp 



i I n i OB8TI fRICAl .l"i k.n \ i .." 1": \ i I >< 



n \ ear, sec 



p. 28. 



tffc 






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if u< 



■ 










■ 



■ 



LIBRARY OF CONGRESS 




010 924 894 • 



r 

Bi 
WIS 



Hi 







SB 




Kill 



MV 









